n 



A PRACTICAL TREATISE 



DISEASES OF THE SKIN", 



FOR THE USE OF STUDENTS AND PRACTITIONERS. 



JAMES KEYINS'HYDE, A.M., M.D., 

PROFESSOR OF SKIN AND VENEREAL DISEASES, RUSH MEDICAL COLLEGE, CHICAGO ; DERMATOLOGIST 

TO THE MICHAEL KEESE HOSPITAL, CHICAGO ; AND ONE OF THE PHYSICIANS TO THE 

INFIRMARY OF THE CHICAGO HOME FOR THE FRIENDLESS. 



■/ 



v7 




PHILADELPHIA: 

HENEY C. LEA'S SOK & CO. 
1883. 






Entered according to the Act of Congress, in the year 1SS3, by 
HENRY C. LEA'S SON & CO., 
the Office of the Librarian of Congress, at Washington. All rights reserved. 



PHILADELPHIA : 
COLLINS, PRINT! 



TO THE MAN 



LOOKING ACROSS THE ATLANTIC, 

VIEWS "with satisfaction the zeal and fidelity with which the doctrines of 

THE VIENNA SCHOOL OF DERMATOLOGY ARE CULTIVATED IN AMERICA, AKD 
THE RICH AND RIPE FRUIT WHICH FROM YEAR TO YEAR THEY BEAR," 

MOEIZ KAPOSI, 

PROFESSOR OF DERMATOLOGY IN THE UNIVERSITY OF VIENNA, AUSTRIA, 

WHO, BOTH BY WORD AND PEN, HAS SHOWN HIMSELF TO BE A WORTHY LEADER 

OF THAT SCHOOL, AND FITTEST TO WEAR THE MANTLE OF HIS 

RENOWNED PREDECESSOR, 

THESE PAGES ARE, WITH HIS GENEROUS CONSENT, 

RESPECTFULLY 



S»i8iai&*fl. 



PREFACE. 



The increasing recognition of the gravity of many cutaneous 
disorders and of the importance of their accurate study, is shown 
by the rapidly augmenting number of observers in this depart- 
ment of medicine and by the numerous valuable contributions 
constantly made to it, both in this country and abroad. For 
the convenience of the general practitioner it therefore becomes 
necessary at shortly recurring intervals that some one should 
attempt the task of presenting in a comprehensive form the 
results of the latest observation and experience. 

The author is aware of the degree to which he must claim 
indulgence in the present effort to perform this duty. The 
extent of the subject and the limitations of a single volume, 
require the omission of much detail of secondary importance. 
With regard to that which it has seemed propel" to include, he 
has endeavored to write concisely, to set forth only what can be 
held as the truth, to be frank in the admission of the weak- 
ness with which the most skilful physician stands in the pre- 
sence of many grave and not a few benign disorders, and to 
cultivate a wholesome doubt of that which has not been shown 
to be worthy of trust. How far he ma}' have fallen short of 
attaining this end these pages will declare. 

He has to express his indebtedness to the standard works on 
dermatology of foreign authorship, especially the exhaustive 
and invaluable work of Hebra, and the Lectures on the Dis- 
eases of the Skin lately given to the profession by Professor 
Kaposi, which contain the mature conclusions of his vast expe- 
rience. With these should be named the writings of Sir Eras- 
mus Wilson, Dr. Tilbury Fox, Dr. Neumann, Dr. McCall Ander- 
son, Dr. Behrend, and the syphilographers, to whose works 
special reference is made in the chapter devoted to their theme. 
Among the books of American authorship, he is under special 
obligation to the sterling work of Dr. Duhring, of Philadel- 
phia, and to the excellent treatises of Drs. Pift'ard, Fox, and 
Bulkley, of New York. 

All these are named by title in the brief, and selected biblio- 
graphy appended at the close of the volume. No less valuable 

(v) 



VI PREFACE. 

aid lias been obtained by consulting tbe papers of American 
and foreign authors contained in the journals specially devoted 

to diseases of the skin, among which, as tbe representatives of 
tbe English tongue, tbe Archives of Dermatology, lately edited 
by Dr. Bulkley, and the current Journal of Cutaneous and 
Venereal Diseases, edited by Drs. Pitfard and Morrow, deserve 
special mention. 

The author is also very greatly indebted to Dr. Charles 
Heitzmann, of New York, not merely for the information 
gathered from tbe study of his original researches in pathology, 
but particularly for bis kindness in furnishing advanced sheets 
of the chapter on the skin, in his work on Microscopic Mor- 
phology, which has just issued from tbe press. From this work, 
with Dr. Heitzmann's permission, several illustrations have been 
borrowed, which appear in the chapter on anatomy, the details 
of which subject are also very largely drawn from the same rich 
store. Tbe first of tbe drawings representing sections of tbe 
skin, is from the faithful pencil of Dr. H. D. Schmidt, of Xew 
Orleans, who, in order to produce it, interrupted, without hesi- 
tation, his arduous labors in connection with the subject of pa- 
thology. To bis colleague, also, Dr. Frederick W. Mercer, of 
Cbicago, the author is glad to express his indebtedness for the 
skill with which a number of pathological specimens have been 
prepared and mounted for special study, and original drawings 
produced for tbe first and several subsequent chapters of tbe 
book. To Dr. Dubring, of Philadelphia, be is further indebted 
for valuable suggestions made during the course of preparation 
of tbe manuscript. 

Medicinal measures are, in these pages, expressed in terms of 
both tbe apotbecaries' scale and the metric system. It is to be 
noted, however, that the latter are not in all cases literal trans- 
lations of the terms of the former, many of tbe formula?, espe- 
cially those for preparations designed to be topically employed, 
being metrically composed the relative proportions of the ingre- 
dients remaining unchanged. 

The changes which it has been advisable to make, in tbe 
matter of nomenclature, classification, and other equally im- 
portant subjects, are concisely explained in tbe chapters devoted 
to each. 

ago, No. 240 Wabash Avenue, 

February, 1883. 



CONTENTS. 



Anatomy and physiology of the skin 17 

The epidermis 18 

The corium 22 

Bloodvessels 24 

Lymphatics 25 

Nerves 26 

Pigment 27 

Muscles 28 

Hairs 28 

Hair-follicles 30 

Sebaceous glands 35 

Sudoriparous glands . .37 

The odorous emanations from the skin 39 

The nails 40 

Subcutaneous tissues 42 

General symptomatology 45 

General etiology 56 

General diagnosis 61 

Prognosis 67 

General therapeutics 68 

Classification 77 



DISEASES OF THE SKIN. 

CLASS I. 
INVOLVING PREDOMINANTLY THE COMPONENT PARTS OF THE 
EPIDERMIS AND DERMA,' AND INCIDENTALLY THE APPEN- 
DAGES OF THE SKIN. 

PAUE 

1. Hypersemic 83 

Erythema simplex 84 

Idiopathic erythema 84 

Symptomatic erythema 85 

Erythema intertrigo 86 

2. Exudative Sd 

Erythema multiforme 90 

Urticaria 94 

Urticaria pigmentosa 95 

Eczema 102 

Erythematous eczema . . 103 

Vesicular eczema 104 

Pustular eczema 106 

Papular eczema 1U7 

Eczema intertrigo 109 

( vii ) 



11 CONTENTS. 

Eczema vcrrueosum . 

Eczema Bclerosum 

Acute eczema 

Chronic eczema . 

Eczema of the scalp . 

Eczema of the face . 

Eczema of the lips 

Eczema of the nos< 

Eczema of the ears 

Eczema of the lids 

Eczema of the beard (e. barbae) 

Eczema of the genital organs 

Eczema of the anus and anal region 

Eczema of the nipple and breast of the fe 

Eczema of the umbilicus 

Eczema of the superior and inf< 

Eczema of the hands and feet 

Eczema as it affects the nails 
Dermatitis 

Dermatitis calorica . 

Dermatitis traumatica 

Dermatitis gangrenosa 

Dermatitis venenata . 

Dermatitis medicaments 
Herpes 

Herpes facialis . 

Herpes progenitalis . 

Herpes iris . 
Herpes zoster . 
Impetigo .... 

Impetigo contagiosa . 
Ecthyma .... 
Furunculosis 

Anthrax .... 
Psoriasis .... 

Pityriasis maculata et circinata 
Pemphigus vulgaris . 
Dermatitis exfoliativa generalis 

Pityriasis rubra . 

Pemphigus foliaceus . 
Impetigo herpetiformis 
Lichen ruber 

Lichen ruber acuminatua 

Lichen ruber planus . 
Prurigo .... 
Zoonoses .... 

Equinia (glanders, farcy, malii 

Pustula maligna 
Hypertrophic .... 
Molluscum epitheliale 
Keratoses .... 



male 
mitics 



r.i"E 
109 
110 

110 

111 

140 
143 
14-, 
140 
147 
148 
149 
151 
154 
155 
158 
1.17 
159 
161 
162 
10-2 
164 
165 
165 
16S 
176 
177 
177 
17!) 
180 
183 
184 
188 
190 
193 
198 
214 
214 
218 
219 
221 
223 
224 
224 
224 
226 
228 
226 
226 

230 
230 
285 



CONTENTS. IX 

PAGE 

Callositas (tyloma) 235 

Clavus (corn) 236 

Cornu cutaneum (cutaneous horns) 237 

Verruca 238 

Multiple cutaneous tumor accompanied by intense pruritus . 241 

Ichthyosis 242 

Elephantiasis 246 

Dermatolysis 250 

Sclerema neonatorum 251 

Scleroderma 253 

Morphcea 256 

4. Atrophic 259 

Atrophia cutis 259 

Xeroderma 259 

Blanching atrophy of the skin 260 

Atrophia senilis 261 

Striae et maculae atrophica * ■ . 261 

5. Neoplastic 263 

Lupus erythematosus 263 

Lupus vulgaris 267 

Keloid 273 

Molluscum rlbrosum 276 

Xanthoma 279 

Adenoma 281 

Myoma cutis . . 281 

Rhinoscleroma 282 

CLASS II. 
OF THE SEBACEOUS GLANDS AND PERIGLANDULAR TISSUES. 

1. Anomalies of secretion 284 

Seborrhcea . .284 

Seborrhcea sicca (or squamosa) 285 

Seborrhcea oleosa 2S8 

Comedo 294 

Sebaceous cysts 300 

Milium . 300 

Wen 302 

Asteatosis 304 

2. Exudative 305 

Acne 805 

Acne artificialis 306 

Acne atrophica and acne hypertrophica 306 

Acne cachecticorum 306 

Acne indurata 306 

Acne papulosa 307 

Acne punctata . 307 

Acne pustulosa .... 307 

Acne varioliformis 308 

Acne vulgaris 308 

Acne rosacea . 314 



X CONTENTS. 

CLASS III. 
OF THE SWEAT GLANDS AND PERIGLANDULAR TISSUES. 

PAS! 

1 Anomalies of secretion 318 

Hyperidrosis 318 

Bromidrosis 320 

Anidrosis 321 

Chromidrosis 329 

Budamina 324 

2. Exudative 325 

Miliaria 325 

Miliary fever 328 

Dysidrosis 329 

CLASS IV. 

OF THE HAIRS, HAIR FOLLICLES, AND PERIFOLLICULAR 
TISSUES. 

1. Atrophic 330 

Alopecia 330 

Congenital alopecia 330 

Senile alopecia 330 

Premature alopecia 331 

Alopecia areata 339 

Alopecia furfuracea 337 

Pityriasis capitis 337 

Atrophia pilorum propria 337 

Trichorexis nodosa 398 

Piedra 340 

Canities 340 

2. Exudative 341 

Sycosis non-parasitica 341 

Dermatitis papillaris capillitii ....... 345 

3. Hypertrophic 346 

Keratosis pilaris 346 

Hypertrophy of the hair 348 

CLASS V. 
OF THE NAILS. 

Hypertrophy of the nail 351 

Atrophy of the nail 352 

CLASS VI. 

OF THE BLOOD- AND LYMPH -VESSELS AND PERIVASCULAR 

TISSUES. 

l. Hemorrhagic 353 

Cutaneous hemorrhages 359 

Purpura hemorrhagica (morbus maculosus Werlhoffii) . . 354 

Purpura pulicosa 354 

Purpura rheumatica (poliosis rheumatica) .... 355 

Purpura scorbutica (scurvy) 356 

Purpura simplex 858 

Purpura urticans 356 



CONTENTS. XI 

PAGE 

2. Neoplastic 358 

Angioma 358 

Narvus vasculosus 359 

Telangiectasis 359 

Angioma cavernosum 360 

Lymphangioma cutis 363 

CLASS VII. 
OF THE NERVES. 

1. Anomalies of sensation '. 364 

Pruritus 364 

Pruritus hiemalis 369 

Hyperesthesia 370 

Anaesthesia 370 

Dermatalgia 371 

2. Neoplastic 373 

Neuroma 373 

CLASS VIII. 
OF THE PIGMENT. 

1. Hypertrophic 376 

Lentigo 376 

Chloasma 377 

Melanoderma, or chloasma, cachecticorum .... 378 

Nsevus pigmentosus 381 

2. Atrophic 382 

Albinism 382 

■ Vitiligo 383 

CLASS IX. 
OF THE SKIN WITH INVOLVEMENT OF OTHER ORGANS. 

1. Exudative 385 

The Exanthemata 385 

Rubeola (measles, morbilli) 386 

Rotheln (rubella, German measles, hybrid measles, French 

measles) 389 

Scarlatina (scarlet fever) 390 

Variola (smallpox) 395 

Vaccinia in man 406 

Erysipelas 410 

2. Neoplastic 416 

Scrofuloderma 416 

The papular scrofuloderm (lichen scrofulosorum) . . . 418 

The small pustular scrofuloderm 418 

The large pustular scrofuloderm 419 

Tuberculosis of the skin 420 

Lepra . 423 

Lepra tuberosa 424 

Lepra maculosa 426 

Lepra ansesthetica 427 



XII CONTEXTS. 

PA'iE 

Pellagra 482 

Frambcesia 4:!4 

The Parangi disease of Ceylon ...... 43.) 

Syphiloderma 486 

Chancre 486 

The Syphilodermata 438 

Syphiloderma maculosum 449 

Syphiloderma papillosum 445 

Syphiloderma vesiculosum 4.V3 

Syphiloderma pustulosum . 452 

Syphiloderma hullosum 455 

Syphiloderma tuberculosum 455 

Serpiginous tubercular syphiloderm 45G 

Syphiloderma gummatosum 458 

Syphiloderma infantile, acquisitum et heereditarium . . 45!) 

Chancroid 483 

Carcinoma 488 

Epithelioma (epithelial cancer) 4ss 

Cancer of the connective tissue 496 

Tuberose carcinoma 497 

Melanotic or pigmented carcinoma 497 

Myeloma cutis (sarcoma of the skin) 498 

Inflammatory fungoid neoplasm 502 

CLASS X. 
OF THE SKIN AND ITS APPENDAGES, ALL PARASITIC. 

1. Of vegetable origin 503 

Tinea favosa 503 

Tinea trichophytina 510 

Tinea circinata 510 

Tinea tonsurans 518 

Tinea sycosis 525 

Tinea versicolor 531 

Myringomycosis 535 

2. Of animal origin 536 

Scabies 536 

Demodex folliculorum 544 

Pules penetrans (rhinocoprion penetrans) .... 545 

Filaria medinensis (filaria sanguinis, Guinea vvorm) . . 545 

Cysticercus cellulose 547 

Leptus 547 

Dipterous larva? in and beneath the human skin . . .548 

Ixodes (wood-tick) 549 

Pediculosis 549 

Pediculosis capitis (parasite, the head louse) .... 550 

Pediculosis corporis (parasite, the body louse) . . . 552 

Pediculosis pubis (parasite, the pubic louse) .... 551; 

Cimez lectularius (acanthia lectularia, bugs or bed-bugs) . 558 

Bibliography 561 

IM'KX 503 



LIST OF ILLUSTRATIONS. 



FI3. PAGE 

1. Vertical section of the skin of the thumb, partly diagrammatic . 19 

2. Scalp of a colored man — horizontal section 20 

3. Vascular and nervous papillae 23 

4. Pacinian body, after silver staining, showing superimposed endothelial 

layers 25 

5. Section of Pacinian body, from a duck's bill 25 

6. Transverse section of hair and follicle .... 30 

7. Upper portion of hair-pouch from the human skin .... 32 

8. Lower portion of hair-pouch from the lip of a kitten .... 33 

9. Section of hair-follicle during the formation of a new hair ... 34 

10. Sebaceous gland of the second class from the ala of the nose . . 36 

11. Duct of the sweat-gland within the epithelial layers of the skin . . 37 

12. Coil of the sweat-gland 38 

13. Vertical section of one-half of nail and matrix 40 

14. Implantation of the nail at its border ....... 41 

15. Subcutaneous fat tissue, the fat having been extracted by turpentine . 43 

16. Columnar adiposes . 43 

17. Vertical section of skin after injection, from beneath, of areolar tissue 

with Berlin blue 44 

18. Chronic eczema — vertical section of the skin of the forearm . . 115 

19. Longitudinal section of the third spinal ganglion of the right lumbar 

region from a case of lumbo-inguinal zoster 182 

20. Section of anthrax 194 

21. Vertical section of anthrax 195 

22. Vertical section of skin from a patch of psoriasis of long standing . 201 

23. Molluscous corpuscles 232 

24. The author's case of molluscum epitheliale 234 

25. Varieties of cutaneous horns 237 

26. Varieties of cutaneous horns 237 

27. Vertical section of the summit of a pointed wart .... 240 

28. Ichthyosis hystrix, vertical section 245 

29. Elephantiasis of the foot and leg 247 

30. Section of a lupous nodule . 269 

31. Keloid growths 273 

32. Molluscum fibrosum 276 

33. Large single fibroma .......... 276 

34. Section of a comedo 296 

35. Sebaceous tumors of the scalp, one of them being laid open to show its 

cysts and contents 303 

(xiii) 



LIST OF ILLUSTRATIONS, 



no. 

36. 
37. 
38. 
39. 

40. 
•11. 
■VI. 
•i::. 
44. 
45. 
46. 
47. 
48. 
49. 
50. 
51. 
52. 
53. 
54. 
55. 
56. 

57. 
58. 
59. 
60. 
61. 
62. 
63. 
64. 
65. 
66. 



Tricliorexis nodosa 

Painful neuroma of the skin; external appearance 

Microscopic structure of neuroma 

Vertical section of pustule at the beginning of pustulation 

Vertical section of one-half of an undeveloped pustule in v 

Lepra tuberculosa 

Larynx of leper affected with lepra tuberculosa 
Larynx of leper affected with lepra tuberculosa 
Larynx of leper affected with lepra tuberculosa 
Byphiloderma papillosum .... 
Vegetating condylomata of the vulva. 

Palmar syphiloderm 

Ulcerative tubercular syphiloderm 
Syphilitic gammata of head and face . 
Lea's lamp for fumigation .... 
Epithelioma, vertical section 
The author's case of myeloma (sarcoma) cutis 

Achorion Schi'mleinii 

Epidermis invaded by the trichophyton 
Hair invaded by the trichophyton 
Filaments and spores of the trichophyton from 
patient affected with tinea sycosis . 

Microsporon furfur 

Female acarus, fecundated ; ventral surface 
Acarian furrow, from the lumbar region 

Dcmodex folliculorum 

(Estrus ....... 

Leptus 



Pediculus capitis — male 
Ova of head-louse attached to hair 
Pediculus vestimenti — female 
Pediculus pubis .... 



the 



beard 



in variola 
ariola 



of 



lale 



PAOB 

339 
374 
375 

401 
401 
424 
425 
426 
426 
447 
449 
450 
456 
458 
477 
491 
499 
506 
514 
520 

527 
533 
539 
540 
545 
548 
548 
550 
551 
553 
557 



DISEASES OF THE SKIN. 



I. 

ANATOMY AND PHYSIOLOGY OF THE SKIN. 

The skin of the "human body is its living envelope, intimately 
associated with underlying structures, and by its situation 
brought into intimate relation also with the external world. 
It is a complex, elastic, and sensitive organ, varying greatly in 
different conditions of climate, age, sex, health, and race; and 
differing also in the characteristics exhibited in different locali- 
ties upon the same individual. Thus in color there is a wide 
range between the fair skin of the blonde and the black of the 
negro, between the rosy pink of the infant's palm and the dark 
brown hue of the genital region of the aired. The skin varies 
also in pliability and thickness, being delicate and lax over the 
lids, the lips, and the prepuce; and much thicker and more 
firmly attached over the palms and the soles. 

It is important to note that the appearance of the skin, even 
in conditions of health, also changes within appreciable limits. 
It is the exposed parts such as the face which the eye of the 
physician most frequently searches, and which betray evidence 
of mental emotions, physiological fluxes, sedentary or active 
habits of life, and fatigue or unusual conditions of vigor. 

Viewed externally, the skin is seen to be traversed by super- 
ficial and deeper furrows, dotted by numerous depressions repre- 
senting the mouths of its follicles, and provided very generally 
with coarse or fine downy hairs which are in some parts repre- 
sented by a growth sufficient to conceal the skin from the view. 
By its extraordinary sensitiveness to different degrees of tem- 
perature and to the physical properties of the bodies with which 
it is brought into contact, it becomes, even when unaided by the 
eye, a valuable means of preserving the human frame from ex- 
ternal injury. 

The skin is provided with a natural unguent, the sebum, by 
which it is continually anointed in health, a fact readily appre- 
ciated when the fingers are passed over its surface. It is capable 
of exuding sweat in various amounts, from the aggregate known 
as insensible perspiration to several pounds in the course of 
twenty-four hours. It is capable in a limited degree of acting 
as a respiratory agent, by eliminating carbonic acid gas and ab- 
sorbing oxygen, though the reverse of this may at times be ob- 
served. Aliments, medicaments, and toxic agents of gaseous, 
2 



18 ANATOMY AND PHYSIOLOGY OF TH B SKIN. 

liquid, and even Bolid consistency arc also by it. under favorable 
circumstances, absorbed. 

The complex organ which is called the skin is essential to the 
life of the individual. The Bexual, and possibly other organs of 
the human body, may have their functions arrested or be even 
obliterated by destructive processes, and life still continue, but 
it' the fuuetions of the skin were all suspended for a sufficient 
period of time, the result would be fatal. In its important rela- 
tions alone to the complicated processes by which the heat of the 
body is maintained at a relatively fixed standard, the skin ex- 
hihits its importance to the general economy. It is thus seen to 
be, not an isolated membrane stretched mechanically over an 
artificial machine, but one of several living and potential sys- 
tems of the body, each of which is in intimate union with all 

Ot ImM'S. 

Anatomically considered, the integument proper, including 

under that term the outer or scarf skin and the inner or true 
skin, which lies immediately beneath the other and is superim- 
posed upon a layer of fatty and connective tissue, may be studied 
apart from its appendages. The latter are perspiratory and seba- 
ceous glands, and the hairs and nails. These four appendages 
are properly considered in such connection, as they are all, not 
only accessory to the perfect function of the skin organ, but also 
histologically derived from it. 

The Epidermis. 

'fin-: Scarf-skin, Epidermis, or Cuticle is the most external of 
the several membranes of the body, being in contact on one side 
with the true skin, or corium, and exposed on the other to the 
atmosphere by which it is surrounded. The latter surface is 
therefore relatively the drier, while the former is constantly 
moistened by fluids from the vessels which ramify beneath it. 
Three separate strata are recognizable in its structure ; the outer, 
called the horny layer or stratum corneum ; a layer intervening 
between this and the deepest, known as the stratum lucidum ; 
and lastly, next to the true skin, the mucous layer or stratum 
mueo-um. Like the entire integument, the epidermis differs 
in thickness in different portions of the body, that over the 
palms and soles being greatly superior in vertical section to the 
epidermis which covers the dorsum of these same organs and 
that found in yet more sensitive situations, as in the lids, lips, 
temples, and prepuce. 

The Horsy Later, or Stratum Corneum of the epidermis, is 

relatively the largest of the three, and is made up of superim- 
posed Beriee of flat, imbricated, many sided, dryish and whitish 
epidermal plates, uniformly and closely packed together, which 
are spindle shaped on vertical section. They are unprovided 



THE EPIDERMIS. 



19 



with bloodvessels, pigment or nuclei, though according to Heitz- 
raaun a nucleus is often faintly indicated in the lower portion 

Fig. 1. 




Vertical section of the skin of the thumb, partly diagrammatic. «., stratum corneum, traversed 
by ducts of two glands ; b, rete mucosum with prolongations extending between papillae beneath ; 
between a and b is seen the stratum lucidum ; c, papillary layer of corium. Near the centre 
of the figure is seen a nervous papilla ; d, reticular layer of corium with vascular plexus, nucle- 
ated connective tissue and interspaces ; e, coils of four sweat-glands ; /, fat-globules in the meshes 
of the connective tissue. 



of the stratum corneum. The outermost plates are more wrin- 
kled and curled than those which are typically flattened and 
seen in the deeper portions, being also in such situations com- 



■20 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



pletely lifeless, and moreover proportionately destitute of lil 
they me found at a greater distance from the rete. The exact 
source of these bodies has not been determined. 

The Septum Lucidum, of Oehl, is recognizable under the raicro- 
. as h delicate, brightly colored line, consisting of a double 
layer of transversely disposed, glistening epithelia, differing in 
tran R lucency from those found on either side of it. It thus 
marks with tolerable distinctness the boundary lines of the strata 
immediately above and below it. The latter iscomposed of flat- 
tened occasion ally granular or nucleated epithelia. whose charac- 
teristics resemble chiefly those of the epithelia in the mucous 
layer, and are disposed for the most part in a transverse direc- 
tion. This Beries of epithelia has been termed also the granular 
layer of the epidermis (stratum granulosum i. but its distinction 
from the others does not seem to he sufficiently constant to jus- 
tify its consideration under a separate title. 

Fi<'. 2. 




-*~/c 



$Wv 




Scalp ofa colored man— horizontal section. -/.'. rete mucosum ; Pi, row .if columnar epithelia, 
cut obliquely, supplied with dark-brown pigment granules; Pa, papilla, cui transversely; I>, 
derma. Magnified 500 diameters. (After Heitzmann.) 

The Mucous Later, Stratum Mucosum, Rete Mucosum, Rete 

MaLPIGHI] or MALP1GHIANUM, is the deepest of the epidermal 
layers, and rests upon the corium below. The latter is inti- 
mately united with it by a series of interdigitations which are 
commonly described as prolongations of the derma into the sub- 
stance of the rete, hut it is equally true that the rete sends down 
prolongations into the derma. The two, for reasons which 
doubtless originate in the need of im intimate union to resist 
friction and to insure vascular supply, arc thus closely locked 
together. 

The studies of ffeitzmann have clearly shown the essential 
character and relations of the epithelia in the mucous layer of 



THE EPIDERMIS. 21 

the skin. According to the latter the epithelia represent irreg- 
ularly polyhedral and diffusely colored lumps of living matter 
— protoplasm, or, as it is termed by Beale, bioplasson, which, 
by their relations to each other, constitute a layer of living mat- 
ter on the outer surface of the body, and on all cavities and 
elongations which are in direct or indirect communication 
with that outer surface. These elements are flattened by reason 
of their apposition, and separated from each other by a lifeless 
cement-substance. All are, however, uninterruptedly united to 
each other by means of delicate spokes, formerly known as 
" prickles," spines, or thorns, which traverse the cloak of cement- 
substance. The living matter, which produces a delicate reti- 
culum within each protoplasmic body, its points of intersection 
being termed nuclei, nucleoli, and granules, furnishes the spokes 
already described, which thus produce continuity through all 
the living layers of the epithelial elements, as well as through 
the underlying layers of the connective tissue.. The epithelia 
are unprovided with either blood or lymph vessels ; but, when 
living, are supplied with a large number of nerves, which, in the 
shape of very minute, beaded fibres, traverse the cement-sub- 
stance, and are here in direct communication with the fibrillse 
of living matter; indirectly, therefore, with the reticulum of 
living matter within the protoplasmic bodies themselves. Deli- 
cate excavations in the cement-substance, analogous to the bile- 
capillaries of the liver, and evidently designed to carry the 
nutritive material to the epithelia, have been discovered by 
Arnold, of Heidelberg. 

The cement-substance also exhibits small protoplasmic masses 
or lumps in those situations where the threads which traverse 
it are most distinct. 

The epithelia next the corium are columnar in form, of a dif- 
fuse brownish hue, and arranged with their long axes nearly at 
right angles to the plane of that portion of the corium upon 
which they are superimposed. More externally they have pro- 
nounced polyhedral outlines, and the so-called nucleus of each 
is large and distinct. A contrast is thus presented to the 
flattened plates of the stratum corneum, which do not exhibit 
this feature, and are besides not pigmented, except in the case 
of the negro, where the intense staining of the deepest part of 
the mucous layer is partially extended to the external strata. 
Such staining in the colored race is produced by granules of 
pigment arranged about an unaffected nucleus. 

The living lumps of protoplasm, just described, play the most 
important part in all the pathological and physiological pro- 
cesses observed in the skin. It is probable that, in the embryo, 
all the appendages of the skin are formed directly by their as- 
similative and reproductive processes; and it is certain that, in 
health and disease, they furnish the organic matter of all secre- 
tions. 



■I'l ANATOMY A XI) PHYSIOLOGY OF THE SKIN'. 

It was at one time taught that the living epithelium of the 
mucous layer was nlso the source of the lifeless?, horny plates of 
the stratum corneum. According to this view, the polygonal 
plates of the horny layer represent dried, effete, transformed 
epithelia, which have been gradually removed by growth of new 
elements beneath, from the deeper layers of the si rat um mucosum. 
But at presenl it is generally conceded that this is at least not 
certain, recenl writers, including Langerhans, Duhring, Pittard, 
and others, having failed to establish Buch a fact. Those authors 
point to the absence of intermediate forms between the two 
varieties of epithelial elements, as also to the remarkable stratum 
lucid um which seems to serve as a dividing line between the 
layers of the epidermis on its either side. 

The Corium. 

The Corium, Derma, Cutis Vera, or True Skin, is composed 
of bundles of iibres, whose decussations produce a dense teit- 
work, coarsest toward the subcutaneous fat-tissue, upon which 
it rests interiorly, and finest superiorly in the outermost portion, 
which is in contact with the epidermis already described. Its 
general characteristics are well described by Heitzmann as fol- 
lows: "The bundles are bounded in many instances by a very 
dense basis-substance, representing the elastic fibres, and sepa- 
rated from each other by narrow layers of a cement-substance 
(Thomsa), which, in its chemical features, is kindred to the glue- 
giving basis-substance of the fibrous connective tissue in gen- 
eral. In this cement-substance there are imbedded delicate for- 
mations of protoplasm, greatly varying in amount in the derma 
of persons of different age. They represent formations analogous 
to nuclei, formerly so-called 'connective-tissue cells,' at present 
considered as compact masses, or delicate reticular layers of liv- 
ing matter, which, with a power of five hundred diameters of 
the microscope, look finely granular. The whole glue-giving 
basis-substance of the bundles is traversed by a delicate reticu- 
lum of living matter, in direct union with all protoplasmic 
formations between the bundles, with all blood and lymph ves- 
sels, with all nerves, and with the columnar epithelia, nearest 
to the capillary layer. Only the meshes of the network of the 
living matter contain the glue-giving basis-substance, which, 
as the history of development of the connective tissue demon- 
strates, is produced by a chemical alteration of the lifeless pro- 
toplasmic fluid itself. The bundles of the connective tissue of 
the derma accompany all elongations of an epithelial character. 
They produce the follicles around the root-sheaths of the hair, 
the capsule around the sudoriparous gland, and the layers which 
surround their ducts. The bundles of connective tissue are tra- 
versed in an oblique direction by bundles of smooth muscular 
fibres, by relatively scanty bloodvessels in the derma, by nu- 



THE CORIL'M. 



23 



merous capillaries in the papillary layer, by a perfectly closed 
system .)f lymphatics, and by numerous medullated and non- 
mednllated nerves." 

Pars Papillaris. — -The papillary layer of the corium lies in 
contact with the rete above, and is connected below with the 
deeper reticular portion of the true skin. Between the rete and 
the papillte of the derma a hyaline and structureless membrane 
is often interposed, though its recognition in every section of 
the skin is a matter of difficulty. 

Fig. 3. 



e J 




Vascular and nervous papillfe. a, vessel ; 6, nervous papilla ; c, vessel ; d, nerve- 
corpusculum tactus ; /, transversely divided nervous filaments; y, epithelia of lete. 
Biesiadecki.) 



fibre ; 

(Aft 



The name of this portion of the derma is intended to describe 
its chief characteristic, the existence of numerous digital pro- 
longations of the corium, made up of delicate tibres of connective 
tissue, which do not interlace, and are abundantly provided with 
nuclei. The papillae spring each from a single, or several from 
a common, ovoid base; their bulbous, conical, or blunt apices 
reaching into the rete, which also dips down between them. 
They differ in size in different parts of the body, and also in 
their disposition and shape, being in places arranged in linear 
series, and in others in concentric whorls, with definite centres, 
producing thus crossing furrows, visible to the naked eye, as 
markings upon the outer surface of the epidermis. 



2 I A X A T M Y AND I> H V S I 1. G Y OF THE S K I X . 

Tn horizontal sections of the skin, the papillae, being trans- 
versely divided, appear as circular or ovoid areas, in which can 
lie recognized centrally a transversely or obliquely divided capil- 
lary loop. Between these areas the inter-papillary reticulum of 

tie' mucous layer is seen. 

Two varieties <>!' papillae are distinguished — the vascular ami 
the nervous; the former containing the terminal loops of a 
minute artery and vein ; ami the latter, the ultimate filamentous 
termination of a non-medullated nerve-fibre. 

It is probable that there are minute nervous filaments which 
enter the vascular papilla? in connection with the vessels; and 
i1 is certain that minute capillary vessels ramify in the nervous 
papilla', the distinction between the two being based upon the 
prevailing characteristics of each. By this mutual interdigita- 
tion of rete and corium, not only is the union between the two 
insured against trivial external accidents, hut an immensely 
larger superficies of bloodvessels is obtained than would have 
been possible by a mere juxtaposition of the two membranes. 
The importance of this provision tor vascularization of tin' sur- 
face of the body is apparent in connection with the regulation 
of its temperature. 

Pars Reticularis. — The reticular layer of the corium is made 
up, as has been seen, of interlacing connective tissue bundles, 
with interspaces increasingly larger from without inward. The 
fineness of the bundles increases, on the contrary, from within 
outward, being finest where the minute papillae of the corium 
project into the rete, and coarsest near the subcutaneous tissue. 

Bloodvessels. 

The Arteries and Veins supplying the skin spring from sub- 
cutaneous branches which penetrate the fasciae beneath, and pro- 
ceed by subdivision to be distributed to all portions of the in- 
tegumenl below the epidermis, the distribution being especially 
abundant about the glands ami follicles of the skin, and the 
inferior and superior parts of the corium. They are always more 
abundant upon the flexor than the extensor faces of the extremi- 
ties, dust beneath the papillary layer of the corium there is a 
minutely ramifying plexus of fine capillaries, whose loops extend 
into the papilla? above, as already described. This and the 
coarser plexus in the deeper portion of the derma are so well 
defined that they might well be designated as superior and in- 
ferior partes va-'cularcs of the corium Still a third vascular 
district is found in the subcutaneous connective tissue where 
the ve88els arc numerous. 

The arterioles, which supply the sweat-glands, surround the 
coils of the latter in an elegant plexus (compared by lleitzmann 
to a basket), and terminate in two or three veinlets, one of which 



LYMPHATICS. 



25 



always accompanies the duct of the gland upward as far as the 
papillary layer, where it anastomoses with the vessels of that 
[•art of the skin. The ascending arterioles supply also the seba- 
ceous glands and hair-follicles ; and finally, breaking up into 
smaller and yet smaller branches, furnish a single or double 
capillary loop to each papilla. The capillaries of the papillary 
layer anastomose freely with those transversely arranged in the 
upper portion of the hair-follicle, loops from which also pass to 
the sebaceous glands. The hair-papilla has a vascular supply 
similar to that of the other papillae of the corium. 

Vaso-motor nerves are twined around these vessels in all 
their ramifications. The whole vascular system, as thus ar- 
ranged, plays a most important part in all the healthy and 
morbid processes which occur in the skin, as well as in the sud- 
den physiological changes distinguishable to the eye in the 
phenomena of blanching and blushing. 



Fig. 4 




Pacinian body, after silver staining 
showing superimposed endothelial lay- 
ers (After Renaut.) 



Section of Pacinian body, from a duck's bill. g.L, 
lamellar envelope ; g.h, hyaline zoue of the lamel- 
lar envelope; bt, terminal bulb of the nerve; g.p, 
n.g.p, layer investing the cavity of the body. (After 
Renaut.) 



Lymphatics. 

The skin is supplied with a perfectly closed system of lymph- 
vessels. These are distributed to the subcutaneous tissues, where 
they form a deep layer; a superficial plexus lying also immedi- 
ately beneath the superior pars vascularis of the corium. From 
the latter loops are presumably given off to the papillae, as well 



26 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

us ti) the pilary, sudoriparous, and sebaceous follicles. In tlie 
mucous layer of the epidermis, Heitzmann has also described deli- 
cate <'\-c;iv;iticiis in the cement-substance between the epithelia, 
which Berve as lymph-conduits. 

The formerly described lymph-spaces, with which it was 
thought the lymphatics were in open communication, are now 
known to have no existence. 

Nerves. 

Non- medullated and medullated nerve-fibres are supplied to 
the skin from subcutaneous branches. The Non-Medullatbd 
Fibres form a delicate sub-epithelial plexus beneath the mucous 

layer, from which proceed the very minute and abundant beaded 
filaments which traverse' the cement-substance between the epi- 
thelia. They are supposed to form finally an intimate connec- 
tion with these bodies. Reference has been already made to the 
tine vaso-motor nerves discovered by Thomsa, which are dis- 
tributed to the sheaths of the bloodvessels, and finally lost in 
the latter. Besides these, motor filaments arc sent to supply the 
muscles. Lastly, trophic nerves supply all the secreting organs 
of the skin, and all the protoplasmic formations in every part, 
including the hair follicles. 

Tin: Medullated Xerve-fibres of the skin terminate in the 
Pacinian and tactile corpuscles. 

The Pacinian Corpuscles, named from the anatomist Pacini, 
exist suhcutaneVnisly only upon nerves intended for cutaneous 
supply, and an- small, oval bodies, two or more millimetres in 
diameter. Each consists of a series of concentric, nucleated, and 
vascular capsules, arranged after the manner of the capsules of 
the onion, more closely united at the periphery than at the 
centre, and surrounding a protoplasmic core. The medullated 
nerve, to which the body is attached, gradually loses its myeline 
envelope, and terminates in the centre of this core, alter travers- 
ing the greater part of its axis, in one or several, minutely club- 
shaped, nervous filaments. The myeline sheath is lost in the tissue 
of the concentric capsules. The precise function of the Pacinian 
corpuscle is unknown. Its connection with the tactile sense is 
suggested by its location, since these bodies are most numerous 
in the subcutaneous tissue of the nipple, the penis, the digits, 
and parte similarly sensitive. It bears an evident analogy to 
the organ of vision, each body having a capsular character; each 
being provided with a special nerve-filament, which enters the 
corpuscle at one pole; each also receiving its impressions at the 
extremity of the capsule opposite that where it receives its 
nervous supply. 



PIGMENT. 27 

The Tactile Corpuscles (corpuscles of Meissner, or Wagner,) 
are other oval-shaped bodies found in about one of four of the 
papillse in the pars papillaris of the corium. They are made up 
of finely interwoven spiral connective tissue fibres with minute 
nuclei, which are so spun together as to form a spindle-shaped 
mass, occupying the greater part of the papilla in which each is 
found. A somewhat" denser connective-tissue capsule incloses 
each. Each is penetrated by one or more medullated nerve- 
fibres whose myeline sheath is lost in the fibrous tissue of the 
corpuscle. 

The axis-cylinder divides into numerous delicate nervous 
threads which are irregularly distributed over the surface of the 
corpuscle and also penetrate within, where they possibly have 
an ultimate distribution, though this is not clearly understood. 
Dr Robinson has latel}' shown that the nerve does not terminate 
in the tactile corpuscle but passes beyond it to the rete. 1 The 
office of the tactile corpuscle is without question connected with 
the sense of touch. 

Pigment. 

The hue of the living integument is due in part to the degree 
of vascularity and distension of the vessels in the corium, and 
in part also to pigmentation of the epidermis. This pigmenta- 
tion depends upon a distinct and uniform coloration of the epi- 
thelia, chiefly those found in the lower strata of the epidermis, 
and also to minute granules of pigment entangled in the reticu- 
lum of living matter in the same part. These pigment-granules 
are carbonaceous compounds, their ultimate chemical composi- 
tion resembling that of the pigments used by the artists in oil. 
Extreme variation in the distribution of pigment is noticeable 
both in health and in disease and in individuals and races, being 
at times certainly proportioned to climatic and similar influ- 
ences. This is well illustrated by the wide range between the 
flaxen-haired and pink-eyed albino, and the blackest specimens 
of the negro, each with small exception of African descent. 

The relation existing between the two sources of the skin 
coloration, viz., the blood and the pigment, are interesting and 
suggestive. The eye unaided, looking at the outer surface of 
the body, detects no distinction between these two color sources. 
It is indeed probable that the pigment originates from the color- 
ing matters of the blood. It is certain that solar heat exerts a 
manifest influence upon both, and that in extravasations of blood 
into the substance of the skin every shade of color which can be 
detected in the spectrum can be at times distinguished. 

1 At the sixth annual meeting of the American Dermatological Association, 
Dr. Robinson read a valuable paper, illustrated by numerous drawings of sec- 
tions prepared by himself, demonstrating clearly that both the Pacinian and 
tactile corpuscles are provided with afferent and efferent nerve-fibres. 



28 ANATOMY AND PHYSIOLOGY OF THE SKIX. 

Muscles. 

Striated Muscular Fibres extend from the subcutaneous tis- 
sue into the derma, and in the case of man are found chiefly upon 
the face and neck, where they are the analogues of more power- 
ful skin moving muscles possessed by Beveral of the lower ani- 
mals. Some, as those in the region of the face, serve to give 
expression to mental emotion by the production of movements 
in the features. 

Non-striatbd Muscular Fibres exist, either as minute oblique 
fasciculi in connection with glands and follicles of the skin; or 
as flattened fan like Bheets, such as those found in the integu- 
ment of the scrotum; or as annular bands, such as those which 
surround the nipple. 

In connection with the hair-follicles, where these muscles fulfil 
an important function, they are attached at one extremity to the 
papillary layer of the corium near its upper surface, possibly also 
to the structureless membrane which occasionally may he seen to 
divide it from the rete; and at the other to the outer layer of the 
hair-follicle, somewhat above the plane in which is the apex of 
the hair-papilla. They are said by Tlionisa to be connected with 
the tissue of the derma by elastic fibres twined around the mus- 
cle-bundles. The direction of each is oblique, and the arrange- 
ment such as to include, in a somewhat acute angle made with 
the hair, the sebaceous gland which is connected with the fol- 
licle. These muscles are termed ERECTORES (or arrectores) pilo- 
RUM, from the fact that in the lower animals they serve to 
produce erection of certain hairs or bristles. Such action in the 
human skin is exceedingly limited, though by contraction these 
muscles undoubtedly exert an influence upon the sebaceous 
gland which they include in the angle subtended by the mus- 
cular fibre. They thus aid in the extrusion of the contents of 
the gland; and it is worthy of note that the greatest develop- 
ment of these muscles is in those parts where the sebaceous 
glands are largest and of the racemose variety seen in the scalp 
and scrotum. 

Hairs. 

Hairs are elongated and pointed epithelial filaments, derived 
from the stratum corneum of the epidermis, and implanted in 
depressions in the rete and corium, known as hair sacs, or hair- 
follicles. They are found in all portions of the body except the 
palms and soles, the dorsum of the distal phalanges of the hands 
and feet, and the skin of the penis. Hairs occur in three toler- 
ably distinct classes. There are the fine downy hairs, or lanugo, 
covering the face, trunk, and limbs; the long and soft hairs, 
such as are implanted upon the scalp, pubes, and axillae; and 



HAIRS. 29 

the short hairs, including the soft variety seen upon the brow, 
and the stiff' hairs of the lids. 

The shaft of the hair is that portion which extends from its 
exit at the surface of the skin to its extremity. The latter, 
when uncut, always tapers to a perfectly acuminate point, as is 
illustrated in the uncut hairs of the lids, and of the lower ani- 
mals. The shaft is either straight, curled, wavy, or alternately 
varied in diameter, producing the peculiar character of the 
growth seen upon the scalp of the negro, these variations being 
due to the different degrees of flattening of the shaft in a trans- 
verse direction. In consequence of the variability in the pig- 
ment which they contain, hairs differ also in color, from a 
snowy whiteness to the darkest black. 

The membrane which invests the shaft of the hair is called 
the cuticle, and is composed of numerous flattened plates, regu- 
larly overlaid so as to resemble fish-scales when viewed under 
the microscope on the flat side, and the overlapping shingles of 
the roof of a house when seen on the edge. 

The cortical, or main substance of the shaft of the hair, is en- 
wrapped by the cuticle, and is composed of flat, nucleated, fusi- 
form, epidermal scales. The strength, elasticity, and extensi- 
bility of the hair are chiefly due to the cortical substance, and 
in particular to the firmness with which these epidermal scales 
are attached to each other. 

The medullary substance of the hair is found best developed 
in the short and strong hairs of the beard and eye-lashes, being 
wanting in the lanugo hairs. It consists of a loosely packed 
mass of epidermal elements, differing in shape, developed in the 
centre of the axis of the shaft, often after extraction of the hair 
intermingled with air bullae. This part of the hair contains 
also the pigment and fatty matters which are here developed as 
in the rete of the epidermis. Seen under the microscope, the 
medulla appears as a continuous or interrupted longitudinal 
band, extending from the bulb, or the part implanted in the fol- 
licle, to the extremity or point. The purpose of this difference 
in the constitution of the cortex and medulla of the hair is 
doubtless to insure, on well-known mechanical principles, a 
maximum of strength, flexibility, extensibility, and elasticity, 
with a minimum of volume. 

The coloring matter of the hair is stored in both its horny and 
medullary portions, and is distinct both within and between the 
epithelial elements of which it is composed. This pigmentation 
corresponds, as Heitzmann has shown, in great part to the 
amount of pigment distributed to other parts of the integument, 
and sustains a close relation to the general nutrition of the 
body. Its subjection to the influence of the trophic nerves is 
well demonstrated by the phenomena of rapid blanching of the 
hairs. Excessive sweating, whether physiological or induced 



:;o 



ANATOMY AND PHYSIOLOGY OF THE SKIN, 



by the action of pilocarpine, has also a distinct influence upon 
the shade of color of the hair. 

On transverse Bection hairs present an ovoid or ellipsoidal 

outline, occasionally suggesting an ir- 
regularly com pressed circle. The de- 

gn f this flattening differs in different 

races, and, as has been intimated, is the 
cause of variability with respect to 
straightness or curliness. As hairs are 
to a marked degree hygroscopic, and 
not only absorb but can be deprived of 
a portion of their water, these states of 
curliness or waviness are Buhject to 
variation according to the aqueous con- 
dition of the media by which an indi- 
vidual is surrounded. 

The bulb or root of the hair is that 
portion which is imbedded in the skin, 
toward which the shaft gradually in- 
creases in thickness as it descends. It 
is implanted below at the base of the 
sac upon a nipple-shaped projection of the corium, which repre- 
sents one of the vascular papillae of the pars papillaris. The 
latter is the chief source of the nutrition of the hair, and, like 
the other digitations of the papillary layer, is made up of delicate 
fibrous or myxomatous connective tissue, traversed by a number 
of capillary bloodvessels, with accompanying vaso-motor nerve- 
fibres. The bulb of the hair which embraces the papilla is a 
knob composed of living elements which, according to Ileitz- 
mann, resemble those of the inner root sheath, to be presently 
described. 




'I i a i averse section of hair 
follicles. 



Hair-Follicle. 

The hair-follicle is a sac-like depression in the corium, in 
which the ha ir-ti lament is implanted by its hull) and there firmly 
secured. The direction or set of this follicle is always at an 
oblique angle with the plane of the cutaneous surface where it 
opens; and thus is determined the set of the hairs, which is al- 
ways fixed and at a similar angle. Viewed as a whole, the in- 
tegument of the body over its entire area exhibits determinate 
whorls of both short and long hairs with definite centres, such 
as those which may he recognized at the vertex of the seal}), the 
centres of the lips, the umbilicus, etc. By this disposition the 
symmetrical appearance of the hairy parts is preserved, and, as 
a consequence of the same provision, physiological loss of the 
hair is not productive of deformity, but rather adds dignity to 
the aspect of the elderly man. 

The description which follows of the anatomy of the hair-fol- 
licle and of the relation which the hair sustains to it, is con- 



HAIRFOLLICLE. 31 

densed from the observations of Heitzmann, based upon his late 
original and accurate studies of this part of the skin. 1 

If the hair-pouch were made artificially by thrusting into it 
from without inward a blunt-pointed pin, before which the tis- 
sues were gradually pushed, it is evident that the external layer, 
the stratum corneum, of the epidermis would be first depressed 
and finally cover the inner surface of the pouch. This repre- 
sents the inner root sheath of the hair. Next to this the pin 
would carry before it the mucous layer of the epidermis, which 
then would form the outer root-sheath of the hair. Outside of 
both would lie the connective tissue of the corium ; this is the 
hair-follicle. 

In this artificial conception, some modifications are required 
by the relation of the parts as actually determined by observa- 
tion. Thus the stratum corneum of the epidermis, as it turns 
downward to form the inner root sheath, loses gradually in 
width till, in the middle of the pouch, not more than two strata 
are visible. At the bottom of the follicle, on the contrary, it in- 
creases in width till it is composed of three or four layers which 
have lost their horny character and acquired protoplasmic fea- 
tures. Here, indeed, is a transitional stage between the lifeless 
stratum corneum and the living rete mucosum, which may well 
arrest the attention of the student of histology, as it may yet 
furnish an explanation of the relation of the one to the other in 
the exposed portions of the integument. 

The rete mucosum enters the pouch in its full width, the epithe- 
lia retaining their protoplasmic character, though gradually re- 
ducing in number till they are represented by but a single layer, 
this last disappearing completely at the bottom of the follicle. 

Supposing that a blunt-pointed pin were now pressed from 
within outward against the base of this epithelial pouch, in a 
line corresponding with the direction observed by the connective- 
tissue bundles, it is clear that the pouch would be again turned 
upward, and that the inner root-sheath would be exclusively 
involved. The resulting epidermal elongation, agreeing in main 
features with the inner root-sheath, represents the hair. The 
hair, therefore, is a solid elongation of the hollow inner root- 
sheath, and is produced by the latter exclusivelj r . 

If now the rete mucosum, or its representative, the outer root- 
sheath, were pushed by the same pin downward and in a lateral 
direction on the side of the acute angle of the obliquely im- 
planted pouch, a smaller depression would result, representing 
the sebaceous gland. The latter is found to be produced exclu- 
sively by the outer root-sheath, and the inner root-sheath to 
take no part in its formation. 

Viewed somewhat more closely, the innermost portion of the 

» 

1 Heitzmann's Microscopic Morphology of the Animal Body in Health and 
Disease, New York, 1888, chapter xiv. the Skin, p. 553 ; also a paper entitled 
"A Contribution to the Minute Anatomy of the Skiu," Chicago Med. Jour, and 
Exam., Dec. 1881. 



32 



ANATOMY AND PHYSIOLOGY OF THE SKIX. 



connective-tissue bundles, which constitute the outer invest- 
ment of the pouch, are found to exhibit cross-sections of smooth 
muscular fibres; and the papilla itself is seen to he a product 

of the follicle. The inner root-sheath also of the hair widens as 
it approaches the bottom of the pouch, and exactly at the lower 
level of the latter is reflected, producing first the hull) of the 
hair, then its root, finally its shaft; the innermost layer of the 
inner root-sheath, in the same process of reflection, forms the 



Fig. 7. 

- 






•^ 



<¥.| 



FG-;- 



JiTA 



>uv 





Upper portion of hair-pouch from the unman .skin B, epidermis ; R.3f, rote mucosum ; P /.. 
papillary layer; /', derma; F, follicle ; It, arreetor i>ili muscle; S. O, sebaceous gland; U.S, 
outer root-sbeath ; T.8, inner root-sheath ; C, cuticle ; B, root of hair. Magnified 150 diameters. 
(After Beitzmann.) 

hair-cuticle, a layer singly investing both the root and the shaft 
of the hair. Between the outer root-sheath and the follicle is 
the homogeneous, structureless membrane, which may be also 



HAIR-FOLLICLK. 



33 



recognized at times between the corium and rete of the skin 
above. The arrector pili muscle connects with the muscle layer 
of the follicle, and surrounds the bottom of the sebaceous gland. 
The pouch at its free extremity is funnel-shaped, and lined with 
stratified epidermal scales, directly traceable to the inner root- 
sheath, which begins in the neck of the pouch. It is composed 
of two layers, that in this situation being named after its dis- 
coverer, Henle. Within, the inner root-sheath is in contact with 



Fiar. 8. 




Lower portion of hair-pouch from the lip of a kitten. F, follicle ; T, transverse sections of con- 
nective-tissue bundles of derma ; M, arrector pili muscle ; IS, inner root-sheath ; OS, outer root- 
sheath ; P, papilla; O, cuticle ; R, root of hair; H, hyoline, or so-called structureless membrane. 
Magnified 500 diameters. (After Heitzmann.) 

the delicate cuticle of the hair, the latter ensheathing both 
root and shaft. The duct only of the sebaceous gland is lined 
with flat horny epithelia. Its acini, like those of other acinous 
glands, exhibit cuboidal epithelia. The duct opens into the 
funnel-shaped widening of the pouch in the space between the 
3 



34 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



inner root-sheath and the cuticle of the hair. The several strata 
of the outer root-sheath are also composed of cuboidal epithelia, 
columnar-shaped elements resting only upon the structureless 
membrane. The inner Burface of the latter is covered by deli- 
cate, flat end othelia, connected by protoplasmic threads with the 
columnar representatives of the deeper rete in the skin above. 
Studying in detail the lower extremity of the hairpouch, its 
upper portion exhibits the light, 
horny llenle's layer of the inner 
root-sheath. In an oblique line 
appear polyhedral epithelia; in 
the upper portions pale, and finely 
granular, with indistinct nuclei; 
deeper down, coarsely granular, 
and slightly elongated. This part 
of the inner root-sheath repre- 
sents what has been termed "* Hux- 
ley's layer." This, at the bottom 
of the pouch, is reflected over the 
papilla, and constitutes the bulb 
of the hair-root. On the lower 
periphery of the papilla are co- 
lumnar epithelia, which are grad- 
ually transformed into first cu- 
boidal, higher up into elongated, 
spindle-shaped elements, and final- 
ly into the horny spiudles, which 
produce the main bulk of the hair. 
The boundary line between the 
inner root-sheath and the root of 
the hair is represented by a thin, 
apparently structureless layer, on 
one side of which is the inner 
root-sheath, and on the other the 
hair cuticle. The latter, on the 
upper portion of the root, as well 
as on the shaft, is composed of 
thin, imbricated scales, described 
above. The epithelia of the cuti- 
cle of the root gradually assume 
a columnar shape and become nu- 
cleated. At the height of the 
bulb they are large, pale, granu- 
lar, and supplied with large and 
distinct nuclei. A characteristic 
row of these is seen in the middle 
between Huxley's layer and the 
bulb; and this at last blends with the cuboidal epithelia on 
either side. Outside of the cuticular row another thin layer of 
pale, flattened epithelia corresponds to the innermost struct ure- 




Section of hair-follicle during the forma- 
tion of a new hair. (After Ebner.) a, ex- 
terna] and middle root-sheaths ; b, vitreous 
membrane ; c, papilla, with va.-c-ular loop; 
.'i root-sheath ; e, internal root- 
sheath ; /, cuticle of hair-follicle; g, cu- 
ticle of hair; /», i, young hair; /, bulb of 
.ilil hair ; ft, debris of external root-sheath 
of hair recently ex pi I Led. 



SEBACEOUS GLANDS. 35 

less layer of the inner root-sheath. The middle portion of the 
bulb is often tilled with globular, indifferent, or medullary cor- 
puscles, pigmented in various degrees, which also fill the central 
portion of the root. Even in strong hairs, however, this may be 
wanting. 

The upper portion of the outer root-sheath is composed of 
epithelia in strata, of which the external layer is columnar. 
This is the last left, as the outer root-sheath approaches the 
region of the bulb, and, becoming thinner, is lost finally at the 
level of the height of the bulb, into whose formation it does not 
enter. 

External to the follicle is the fibrous connective tissue of the 
derma, in longitudinal and transverse bundles. At its base a 
fibrous connective tissue pedicle is often seen extending to the 
subcutaneous tissue. 

Heitzmann shows, furthermore, that the new growth of a hair 
takes place exclusively within the inner root sheath. The latter, 
below the bulb of the old hair (which is fringed by torn epidermal 
scales) widens, is again involuted, and forms a new bulb, com- 
posed of embryonal corpuscles. The boundary between these 
two portions of the inner root-sheath is established by the cu- 
ticle, which, below the bulb of the old hair, is composed of 
columnar epithelia. When pigment is discovered, it lies exclu- 
sively in the central portion of the inner root-sheath, from which 
the new springs. In this the outer root-sheath takes no part. 

The hairs are developed in the third month of intra-uterine 
life by budlike projections from the epidermis downward, the 
bottom being subsequently projected upward by connective tissue 
extension. The epithelia, originally medullary in character, 
elongate, flatten, and are finally transformed into the hair and 
its root-sheaths. 

Sebaceous Glands. 

The sebaceous glands are pyriform bodies, usually racemose 
in development, situated in the corium, never in the subcuta- 
neous tissue, and designed to furnish the natural unguent of the 
human body. The plan of their development from the outer 
root-sheath of the hair - follicle has been already described. 
Externally, each is limited by an outer coat of connective tissue, 
within which is a layer of nucleated cuboidal epithelia flattened 
by juxtaposition, continuous with and. similar in character to 
those constituting the mucous layer of the epidermis. Several 
layers of these can be recognized in each acinus of the gland. 
In this situation the epithelia undergo a fatty metamorphosis, 
by reason of which the semi-fluid, amorphous, greasy substance 
is produced w r hich is known as sebum, or sebaceous matter. 

Three classes of sebaceous glands, as they are divided by Sap- 
pey and Piffard, are readily distinguished. There are, first, those 
which serve as appendages of the hair-follicles and hairs. These 



36 



ANATOMY AND PHYSIOLOGY OF THE SKIN, 



occur in connection with the long and soft hairs, as of the scalp 
and axillae, several at times grouped around a Bingle hair-sac. 
They are usually found lying along the upper third of the fol- 
licle and, in such case, the Bebum is extruded into the latter 
before arriving upon the free surface of the skin. 




Fie. 10. 






Sebaceous gland of the second class from the aire of the nose. (After Sappey.) 



The second class includes the large and complex glandular 
structures to which the lanugo or rudimentary hairs seem 
accessory, the orifice of their ducts opening directly upon the 
cutaneous surface. These are chiefly found' upon the so-called 
non-hairy portions of the skin, as the face in both sexes, and 
portions of the trunk and extremities. The third class, em- 
bracing by far the smaller number, are the sebaceous glands 
entirely unconnected with hairs and their follicles. Such are 
the glanduls odoriferse of the male and female genitalia, and 
those seen in the areola of the nipple of the female breast. No 
sebaceous glands exist upon the palms, the soles, and on the 
dorsum of the distal phalanges of the hands and the feet. 



SUDORIPAROUS GLANDS. 



37 



The office of the sebaceous glands is evidently the protection 
of the human body both from undue loss of water by evapora- 
tion and the consequent desiccation of the surface, as also from 
undue absorption when immersed in the same fluid. This latter 
office is well illustrated by the action of the vernix caseosa of 
the foetus, in consequence of which the new being is for a period 
of several months, so long as life is sustained, preserved from 
the macerating influence of the liquor amnii. 

In chemical constitution, the sebum is found to consist of 
olein, palmatin, cholesterin, and the saline constituents of the 
other animal products. It has been already shown that the 
extrusion of the secreted sebum from its gland, is greatly favored 
by the action of the arrectores pilorum muscles, by which on 
the one side the latter is compressed against the hair-follicle on 
the other. 

Sudoriparous Glands. 

The sweat, or sudoriparous glands, are elongated tubules ex- 
tending obliquely from the surface of the body to the deeper 




Duct of the sweat-gland within the epitheiial layers of the skin. BP, papilla with injected 
bloodvessels ; V, valley between two papillaj ; D, duct in the rete mucosnrn ; E, E, epidermal 
layer ; PL, coarsely granulated epithelia, deeply stained with carmine ; P, duct with corkscrew 
windings in the epidermal layer. Magnified 200 diameters. (After Heitzmann.) 

portions of the corium, or, in certain localities, to the subcuta- 
neous tissue, terminating in the latter situation in a glomerulus 
or coil. They serve for the excretion of sweat. The sudoripa- 
rous glands are found in all parts of the body, being developed 
more abundantly and in larger size in certain special regions, 
as the axillse, the groins, the palms, and the soles. 

The long duct of this small reddish-yellow body, beginning 



38 ANATOMY AND PHYSIOLOGY OF THK SKIN. 

as a coecal pouch within the coil or glomerulus, ascends in a 
nearly vertical direction to the surface, a very gentle spiral 
direction being assumed in this ascent. The excretory duct of 
the gland has a funnel-shaped terminus, and opens at the free 
surface of the integument, often at an angle with the plane of 
the latter. s<> that a Bpecies of minute valvule is formed hy those 
plates of the horny layer superimposed upon the superior portion 
of the duet. The orifices of the sweat-glands called "pores" 
are in places visi'nle to the unaided eye, in the furrows between 
the papillary ledges. Under the microscope, the anatomical 
differences between the coil and the duct are seen to depend 
upon the existence in the former of cuboidal, and in the latter, 
as tar as the rete, of columnar epithelia, both attached to a 
deiicate hyaline membrane. In the empty condition of the 
gland the calibre of the tubule is narrow, and the cement ledge 
of the epithelia is plainly visible at the surface bounding the 
calibre. A basket-like plexus of vessels has been already de- 
scribed as surrounding each in the connective tissue capsule of 
the gland. Here also are smooth muscle iibres, chiefly conspic- 
uous in the axilla?. 

The diameter of the duct at its outset does not, according to 
Ileitzmann, exceed that of the lobule within the coil. It soon, 



Fig. 12. 




Coil of the Bweal gland. S, tubule lined by cuboidal epithelia; T, central calibre of the 
tubule; Z>, beginning of the duct ; C\ connective tissue with injected bloodvessels. Maguified 
meters. (After Heitzmann.) 



however, widens and shows a single stratum of columnar epi- 
thelia. Delicate longitudinally arranged bundles of connective 
tissue accompany the duct, though no smooth muscle bundles 



THE ODOROUS EMANATIONS FROM THE SKIN". 39 

are present. The latter leads in a slightly devious course to a 
depression between two papillae, and is here composed of strati- 
fied epithelia representing a formation of the rete prolonged 
within it to a varying depth. After reaching the epidermal 
layer, the duct is lined by a single row of flat epithelia, its 
calibre widening considerably at its orifice upon the surface of 
the skin. 

The sudoriparous glands of the foetus are seen about the fifth 
month of intra-uterine life, and, like the sebaceous glands, appear 
first as flask- or bud-like projections from the columnar epithelia 
of the rete mucosum. As they extend further toward the corium 
the skein of the coil is formed by convolution of the originally 
straight cylindriform column, an axial canal simultaneously 
developing. 

The total number of the sudoriparous glands in the bod} 7 is 
estimated to be between two and three millions, and the total 
length of the uncoiled glands about eight miles. These figures 
serve to give an approximate idea of the immense importance, 
physiologically, of the sweat excretion, and of the extent to 
which violation of the hygienic rules of cleanliness possesses 
interest from the pathological standpoint. 

The sweat excreted by the body differs under varying condi- 
tions of temperature, humidity of the air, and the amount and 
character of the articles ingested by the individual, either as 
food, drink, or medicament. Nearly ninety-eight per cent, of 
the secretion is pure water, the remaining proportions represent- 
ing the saline constituents of the other fluids furnished by the 
animal in life. In all chemical analyses of the sweat, a source 
of error lies in the difficulty of securing the fluid secretion un- 
mingled with that produced by the sebaceous glands; and the 
same, it may be said in passing, is true of the chemical analysis 
of the sebum. According to X)uhring, the iodide of potassium, 
benzoin, succinic and tartaric acids are excreted with the per- 
spiration. 

The Odorous Emanations from the Skin. 

The skin of the human body in health is the constant source 
of odorous emanations, which, in pathological conditions, may 
be greatly increased or otherwise changed. The nature and ex- 
act sources of these emanations are as yet imperfectly under- 
stood. Were these exclusively of a volatile, gaseous, or vaporous 
composition, even though such volatile fluids were capable of 
condensation upon external bodies, this could be scarcely held 
as compatible with the well-known fact that the lower animals 
are, many of them, capable of tracing the track of the human 
being for miles over a wind-swept path, till the soil pressed by 
the foot is covered with water. There is strong reason to be- 
lieve that these emanations are the sole sources by which several 



40 ANATOMY AND PHYSIOLOGY OF THE SKIN". 

of 1 1 1 o contagious and infective diseases are communicated from 
one individual to another, a fact which Buggests that they, at 
times certainly, contain living matter derived from the proto- 
plasmic masses of which the body is built up. These emanations 
are properly regarded as having their origin in the secreting 
Bystem of the skin, but in what proportion the several secreting 
glands participate in the product, is difficult to establish. The 
sweat at times, even to human nostrils, exhales a distinct odor, 
though, as before intimated, to what extent this is due to its 
admixture with the Bebaceous material, it is difficult to deter- 
mine. Peculiarly fetid and disgusting odors occasionally origi- 
nate in chemically altered sebum, where the influence of the 
sweat secretion must lie, from the locality under examination, 
practically eliminated. 

The entire subject is one of great interest, as promising to 
throw light in the future upon many questions connected with 
contagion and infection. Enough is certain to justify the view 
that the human body in health is perfectly enveloped in an 
odorous medium, constantly perceptible to keener nostrils than 
our own at a considerable distance from the surface of the indi- 
vidual and having its source in the secretions of the integument. 

The Nails. 

Nails are concavo-convex plates or shells of horny tissue, 
placed upon the dorsum of the terminal extremities of the distal 
phalanges of the fingers and toes. Each has a free border at the 

Fig. 13. 

& if ¥ 



Vertical section of one-half of nail ami matrix, a, nail substance; h, horny layer; c, mucous 
layer ; ■/, papilla of corium : e, nail furrow destitute of papillae : /, horny layer of the ungual 
furrow rising above the nail ; g, papilla of skin of dorsal Burface of the finger. 

distal portion of the pulp of t lie digit, with sides and proximal 

borders let into distinct furrows of the skin. The convex sur- 
laee of the nail is exposed, the concave regarding the phalanx, 
and being implanted upon the matrix beneath. 



THE NAILS. 



41 



In the substance of the nail proper are recognized tissues 
analogous to the stratum corneum and rete raucosum of the epi- 
dermis, the main portion of the nail substance being horny in 
character, the lower elements exhibiting indistinct nuclei. Its 
growth in thickness is provided by increment from the epithelia 
of the matrix ; and its forward progression over the pulp of the 
digit, by a species of gliding movement in the elements, necessi- 
tated b} r the relatively rapid increase of the horny layer above 
in a longitudinal direction. The nail, therefore, is not physiologi- 
cally pushed forward en masse from its lunula to its free edge, 
but describes in its growth a gentle curve whose outline is indi- 
cated by the projection of the uncut nail over the pulpy extremity 
of the digit to which it is attached. 

The free border of the nail is distinguished by its elasticity and 
its semi-transparency. The ungual folds in which the attached 
edges are confined, are so arranged that an overlapping of the 
epidermis occurs above the nail tissue which it is designed to 
secure in situ. This overlapping is marked by an exquisitely 
rounded ledge, which is itself, in turn, separated from the gene- 
ral surface of the skin of the phalanx, by a delicate furrow. 

Fi£?. 14. 




Implantation of the nail at its border. P, papilla? decreasing in size toward the middle line ; 
S, rete mucosum, which broadens toward the border of the nail, and forms irregular prolonga- 
tions; B', E, epidermal layer ; N, plate of the nail. Magnified 500 diameters. (After Heitz- 
mannj 



The matrix of the nail is composed of the rete and its subja- 
cent eo ri lira, the papillae of the latter being projected somewhat 
forward in the direction in which the nail is to be pushed. 
They are absent in the lateral portion of the nail. The papillae 
here are well developed, arranged in parallel rows and unpro- 



42 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

vided with t';it. but richly supplied with vessels and nerves. 
According to Kaposi, the ungual substance is produced exclu- 
sively by the pars papillaris of the corium, which would thus 
seem to be assigned the rule formerly supposed to be played by 
the papilla at the base of the hair-follicle. But the demonstra- 
tion by Ileitzinann that the hair is formed from its inner root- 
Blieath and not from the papilla, suggests the inference that the 
analogy so faithfully observed by nature in other parts of the 
body, may here also become evident. The nail and the hair are 
alike nourished by their papillae, but do not seem to be formed 
from them. It would he unwise to conclude, for example, that 
the undeveloped foetus of the kangaroo, which is for weeks sus- 
pended at the maternal nipple, was originally developed from 
that organ. 

The whitish disk of define 1 crescentic contour, its convexity 
directed toward the free border, exists in each nail, but is best 
recognized in those of the toe and thumb. It is called the lunula, 
and is produced by the papillae beneath the disk, forming rela- 
tively bloodless laminae of tissue. According to Toldt, cited by 
Ileitzmann, the lunula is caused by diminished transparency of 
the tissues, owing to a broad, uniformly distributed layer origi- 
nating in the rete. 

Subcutaneous Tissues. 

The structure immediately beneath the skin is built up of 
loose connective tissue bundles, prolonged from the aponeuroses, 
the fuscia?, and often from the membranes beneath. It is firing 
attached to the skin over the extensor surfaces of the articula- 
tions, the palms, the soles, and the groin by short and coarse 
bundles, between which are single or multilocular spaces lined 
with endothelia, secreting a mucoid fluid. These are the bursae 
mucosae. Elsewhere, as in the eyelids, the penis, the scrotum, 
and the auricle of the ear, the attachment to the skin is by 
loose, delicate connective tissue, containing no fat globules. All 
other fibrous tracts are arranged obliquely, admit, by their ex- 
tension, of various degrees of pliability, and inclose rhomboidal 
spaces containing more or less numerous fat globules. These 
are lobulated, bounded by a delicate, fibrous connective tissue, 
and abundantly supplied with bloodvessels. This is termed the 
panniculus adiposus. 

The anatomy of the thick cutis vera has been carefully studied 
by Dr. J. Collins Warren, of Boston. 1 The back and shoulders 
of. a vigorous adult are seen to furnish an integument much 
thicker than the hide of many pachydermatous animals. The 
papillae are imperfectly formed, and represented by an undulat- 
ing line. The follicles of the lanugo hairs penetrate only the 

1 Batterthwaite'fl Manual of Histology, New York, 1881, p. 420. 



SUBCUTANEOUS TISSUES. 



43 



superficial layers of the cutis. From the bases of the hair- 
, follicles, nearly vertical clefts, or slender, columnar shaped 



Fiff. 15. 




Subcutaneous fat tissue, the fat having been extracted by turpentine. B, bundle of fibrous 
connective tissue, carrying injected blood-vessels ; C, capsules of fat globules, with oblong 
nuclei. Magnified 500 diameters. (After Heitzmann.) 

Fig. 16. 




Colurause adiposse. (After Warren.) a, epidermis ; b, erector pili muscle ; p, horizontal prolonga- 
tions of the column; c, coil of sweat gland suspended in the latter; /, fibrous bundles of 
corium; g, panniculus adiposus ; lc, band of fibrous tissue extending to the latter. 



44 ANATOMY AM) PHYSIOLOGY OF THE SKIN. 

Bpacea extend obliquely to the panniculus adiposus, which have 
been fitly termed by Warren, " fat columns or fat canals," as 
they are entirely occupied by adipose tissue. 

These columns are about four mm. in length, and are slightly 
wider than the hair-follicles above. Their long axes form a 
slight angle with that of the follicle, hut they are nearly parallel 
to that of the erector pili muscle. Two horizontal prolonga- 
tions are given off on either side of the middle of this axis, 
partly fat-filled. Near this point is suspended the coil of a 
sweat gland, held in place by a few delicate fibres. The duct 
of the gland runs to the top of this space, whence it may be 
traced to the side of the hair-follicle. The connective tissue 
fibres seem to terminate abruptly at the edges of these columns. 
The cleft, slightly widens below, and on the side toward which 
its axis leans, the fibres of connective tissue form a bundle pen- 

Fi". 17. 



3 




I 



lection of skiu after injection, from beneath, of areolar tissue 
(After Warren.) ", epidermis ; /, corium ; g, panniculus adi 



etrating below to the subcutaneous fat. The erector pili muscle 
is inserted partly into the base of the follicle, and partly into 
the apex of the fat canal. 

T hese columns correspond in number to the hairs. The blood- 
vessels which they contain, springing from the subcutaneous 
plexus, bifurcate at the lateral clefts. 



GENERAL SYMPTOMATOLOGY. 45 

II. 

GENERAL SYMPTOMATOLOGY. 

In cutaneous, as in other diseases, the clinical signs or symp- 
toms of the morbid process are those by which it is recognized 
alike by the patient and the physician. It is usual to divide 
these into subjective and objective: the former those appre- 
ciated by the patient alone in consequence of his sensations, 
the latter by the eye and the touch of another who undertakes 
the investigation of the disease. It should be remembered, 
however — and this is a matter of some importance in this 
connection — that many objective signs are made manifest to the 
eye and touch of the patient himself, and liable to be inter- 
preted or misinterpreted by him, with consequences which 
should not be ignored. 

Subjective Symptoms. — The purely subjective symptoms of a 
disease of the skin are those manifested to the patient by sensa- 
tions other than those connected with vision and his own sense 
of touch. They include sensations of itching, smarting, tingling, 
pricking, and burning; sensations as of increased or diminished 
susceptibility to the contact of foreign bodies ; of increased or 
diminished temperature; pain in various grades of severity; 
and disordered sensations, as of the crawling of insects over the 
part, currents of hot or cold vapors or liquids, and compression 
of portions of the skin by either cords, bands, or closely fitting 
plates. The character of the subjective sensations experienced 
by a patient often proves an aid to the physician in recognizing 
the nature, not merely of a present disease, but of one also which 
has preceded. Thus the sensation produced by an attack of 
erysipelas is rarely an itching, while the latter is highly char- 
acteristic of eczema and scabies ; the pain of zoster and the 
tingling of urticaria being distinctly different, not only from 
each other, but from the subjective symptoms named above. 

Objective Symptoms. — The study of the objective symptoms 
of a cutaneous disease is of paramount importance, hi no re- 
spect does the skilled physician so distinguish himself from one 
who is inexpert as in the recognition of the typical or atypical 
objective characters presented in diseases of the skin. The 
study is one which can be neglected safely by no diagnostician, 
and its rewards are precious in every department of medical 
science. These symptoms are spread before the eye, and their 
legibility increases with every hour of careful attention. 



46 GENERAL SYMPTOMATOLOGY. 

These Bigna of skin disease — or, more literally, skin injury — 
arc called lesions, and if is usual to classify them as primary 
and secondary. Such a division is, however, open to criticism, 
since, viewed from the standpoint of time merely, some of the 
so-called primary lesions of the skin become in turn secondary 
and even tertiary. Thus a papule which might at one moment 
he called primary, may he transformed wholly or in part into a 
vesicle, which thus becomes a secondary lesion; and such vesicle 
again, in the evolution of a disease, may become a tertiary pus- 
tule. The latter finally may result in a quaternary crust. In 
the following pages these elements of skin diseases will be 
described as lesions and lesion-relics. 

LesIons. — In describing the average size of cutaneous lesions, 
it is less convenient to state their measurement in fractions of a 
line or millimetre than to convey an approximate idea l>y a 
comparison with familiar objects of relatively fixed dimensions. 
The objects usually selected for this purpose are, beginning with 
the smallest, the seeds of poppy, mustard, and rape; the coffee- 
bean; the pea; the bean; the cherry; the finger-nail; the chest- 
nut; the horse-chestnut; the egg of the hen and of the goose; 
and the orange. To these may also be added the point and the 
head of a pin. The student will find it useful to familiarize 
himself with the size of the small seeds mentioned, that then- 
names may at once suggest to him the relative size of the lesions 
to which they are compared. 

Maculae, spots or stains, are generally circumscribed al- 
terations in the color of the integument, differing as to the 
size, shape, hue, and duration of the dyschromia. 

Examples of macula; are to be found in the exanthematons 
rashes (measles); in localized hyperamiise of the capillary plexus 
of the corium, disappearing in various degrees according to the 
pressure exerted on the part (rosacea); in visible acquired devel- 
opment of bloodvessels in the skin (telangiectasis); in congenital 
vascularization of the surface (nsevi); in variously colored blood 
extravasations and stases (purpura); in stains produced by con- 
tact with dyes (hand-workers in aniline); and in pigmentary 
changes such as those produced by solar heat (freckles), or by 
leprosy. 

Extensive non-circumscribed changes in the skin color are 
seen in the course of several general disturbances of the economy, 
as in yellow fever, cancer, chlorosis, albinism, Addison's disease, 
argyria, and icterus. 

Spots of various color and device are also produced by the 
intentional or accidental introduction of pigmented particles 
beneath the skin, as by the process of tattooing, 
of gunpowder, etc. 



lesions and lesion relics. 47 

Papula are soltd or compressible, ephemeral or persistent, 
circumscribed projections from the surface of the skin, vary- 
ing in size from a poppy seed to a coffee-bean. 

These exceedingly common skin symptoms vary greatly in 
their shape, color, location, career, and significance. Thus they 
may be flattened at the apex, acuminate or pointed, conical, 
rounded, or depressed at the summit to form an umbilication. 
They may be pale, rosy, dark or lurid-red, purplish, or even 
blackish. They may develop in transitory or persistent pro- 
cesses ; they may be transformed into lesions containing fluids ; 
may desiccate and furnish scales either at apex or base; may 
degenerate into ulcers, or enlarge into tubercles or tumors. They 
may be scratched, torn or rubbed so as to lose their typical ap- 
pearance; they may come and go; be sensitive to sudden changes 
in the blood-current, and yet be themselves persistent. 

The mixed forms described above are generally named 
vesico-papular or papulo-vesicular, papulosquamous, papulo- 
pustule, etc. 

Lesions which simulate the papule and which, though described 
under that title, really belong to another category, are the small, 
semi-solid elevations of the surface which occur at the orifices 
of the ducts of the cutaneous glands and follicles. Thus they 
may consist of little heaps of epidermis about the hair follicles 
(lichen pilaris, keratosis pilaris), or of inspissated sebum collected 
in one or all of the acini of the sebaceous glands (milium, 
comedo). 

The concomitants of an eruption of papular type also vary. 
Thus there may be a febrile process, or extensive infiltration or' 
the skin about and beneath the papules (prurigo); or itching of 
the most intolerable character (eczema papulosum) ; or produc- 
tion of trifling sensations of annoyance, as a slight burning 
without other subjective symptoms (acne, lichen planus). 

Papules which are transformed into moist lesions become 
covered with a crust. Papules which are scratched or torn by 
the finger nails usually betray the fact in the minute and flat 
blood-scale dried upon their surface. Papules which ulcerate 
may be followed by scars. Papules which have undergone the 
process of involution may be followed by macular sequelae. 

Wheals are more or less transitory, rosy-red and whitish, 
irregularly shaped and sized elevations of the surface of 
the skin, produced by blood-stasis in spasm of the vessels, 
accompanied by a tingling or pricking sensation and charac- 
terized by rapidity of evolution and frequency of recurrence. 

The typical wheal is seen in the disease known as nettle-rash 
(urticaria), where closely packed, shining, roundish and whitish 
pea to finger-nail sized elevations of the skin are visible, sur- 
rounded by a slightly rosy border. They are firm to the touch, 
and occur in patches, circles, bands, gyrations or striations, often 



48 GENERAL SYMPTOMATOLOGY'. 

disappearing in a brief time and recurring with or without a 
renewal of the cause. They are occasioned by a rapid exudation 
of serum into the rete or pars papillaris of the corium. This 
is supposed to be due to clonic vascular spasm, producing irreg- 
ularities in the lumen of the skin capillaries, under the influence 
of the vaso-inotor nerves which supply a small area of the superior 
pare vascularis of the derma. The sensations produced by the 
wheal arc particularly stinging, burning, pricking, and itching. 

" Giant" wheals are such as enlarge to the dimensions of an 
egg or a tomato, or cover extensive areas of integument, as for 
example the entire surface of the buttock or shoulder. 

Relics of disappeared wheals are usually transitory erythema- 
tous maculae, but in rare cases a more or less deep pigmentation 
is left, which slowly disappears (urticaria pigmentosa). 

It should be borne in mind that at times the wheal-like con- 
dition is assumed by the papule, as also the lesions resulting 
from such traumatism as the bite of insects, reptiles, horses, 
dogs, etc. 

Tubercles are solid, generally incompressible and persis- 
tent, NODOSITIES OF THE SKIN, VARYING IN SIZE FROM A COFFEE- 
BEAN TO A CHERRY. 

They may be largely projected from the free surface of the 
integument, or be deeply seated in the skin, and but a small 
portion become evident to tbe view externally. Their varieties 
as to shape, color, size, and other features, correspond in great 
part to those described in connection with papules. They may 
be attached by a broad base to the skin, or be pedunculated or 
even pendulous. Their seat is usually in the deeper portions 
of the corium or the subcutaneous connective tissue. Degener- 
ating and ulcerating tubercles are followed, as might be sup- 
posed in view of their volume, by considerable destruction of 
tissue, and in cases of repair by correspondingly extensive cica- 
trices. Tubercles are seen in such diseases as molluscum tibro- 
sum, molluscum epitheliale, syphilis, leprosy, myeloma, and 
cancer. 

Tubercles are often described as merely enlarged papules; but 
the distinction between these two forms of lesion will be better 
recognized when attention is paid to the particular portion of 
the skin in which each takes its origin. Papules spring oftenest 
from the superficial layers of the derma; tubercles, on the other 
hand, from the deeper. This being remembered, it will be clear 
that at times a tubercle may project from the surface to a less 
extent than a papule, though its larger volume is evident as 
soon as the skin within which it has developed is handled. 

Tumors are masses of solid tissue, or of solid tissue more 
or less commingled with fluids of variable consistency, dif- 
fering in size, shape, color, and in the benignity or malignity 



LESIONS AND LESION- RELICS. 49 

OF THEIR CAREER, EITHER LOCATED WITHIN OR BENEATH THE SKIN, 
OR, BEING ATTACHED TO THE LATTER, PROJECTING FROM IT TO A 
VARIABLE EXTENT. 

The mere fact that, a lesion of the skin approaches in dimen- 
sions the size of a tumor is in itself an element of gravity. 
Tumors may originate in mere hyperplasia of the living matter ; 
may consist of new formations of greater or less danger to the 
vicinage, or the general economy; may be formed of blood or 
lymphatic vessels, or both in the same lesion; may embody 
large fluid-containing cysts; may be built up of nervous tissue, 
fat, bundles of connective-tissue fibres, glandular elements, and 
indeed of any of the elements which exist physiologically in the 
human integument. 

Examples of tumors are seen in molluscum fibrosum, myeloma, 
wens, cancer, and rhinoscleroma. 

Vesicles are elevations of the horny layer of the epi- 
dermis WITH LIMPID, LACTESCENT, OR SANGUINOLENT FLUID CON- 
TENTS, VARYING IN SIZE FROM A POPPY-SEED TO A COFFEE-BEAN. 

Typical vesicles are seen in the minute and transitory lesions 
occurring in the vesicular form of eczema. They are usually 
filled with a clear serum. Variations from this type are, how- 
ever, common. Thus, they may be flattened, acuminate, round- 
ish, umbilioated, or conical ; may be fully distended or partially 
collapsed upon their contents; may have a short or long dura- 
tion; may be distended with milky, chylous, or a blood-stained 
fluid; may be opalescent, yellowish, reddish, or blackish in color; 
several may coalesce to form a many-chambered lesion ; and a 
single one or several such may undergo transformation into pus- 
tules or bullae. Vesicles may terminate by accidental or spon- 
taneous rupture, their contents freely flowing forth upon the 
surface of the peripheral integument; or they may desiccate to 
a crust, or may even terminate by one of the ulcerative pro- 
cesses. They may or may not be accompanied by pruritus. 
Minute vesicles, which are merely the external apices of large- 
chambered accumulations of fluid beneath, occasionally form 
upon the surface of the skin. 

Such are seen in the course of lymphangiectasia. 

Blebs, or bullae, are superficial or deep-seated elevations 
of the skin having fluid contents, differing in color, shape, 
and career, and varying in size from a coffee bean to a 
goose's EGG. 

Blebs have been described as large vesicles; but this fails to 
define exactly their pathological character. Like vesicles they 
may contain serum, lymph, blood, or pus; and be variously 
colored in the degrees according to which their contents become 
visible through a semi-transparent roof-wall. They may be glo- 
boid, hemispherical, oval, crescentic, semi-crescentic, conical, and 
4 



50 GENERAL SYMPTOMATOLOGY. 

even exhibit angles. They may be seated upon an apparently 
unaltered or evidently morbid integument; and may or may 

not present a peripheral areola. 

Bullae may persist or rupture; ma} T desiccate or degenerate 
into ulcers; 'may collapse after tlie escape of their contents, and 
the roof-wall become glued to the base from which it was origi- 
nally raised. 

Bullee usually occur in extremely debilitated states of the 
Bystem, and are, as a rule, of graver portent than other fluid- 
containing lesions of the skin. " They occur in scalds and burns, 
in pemphigus, leprosy, erysipelas, syphilis, and moist gangrene. 

Pustules are circumscribed cutaneous abscesses, covered 

WITH AN EPIDERMAL ROOF-WALL, AND VARYING IN SIZE FROM A 
MILLET SEED TO A FILBERT. 

The typical pustule contains pus, and is colored yellowish, 
yellowish-green, or brownish green, according to the admixture 
of its contents with blood. The pus being an inflammatory 
product, it necessarily indicates the occurrence, at the base of 
the pustule, of an inflammatory process. Pustules, like vesicles, 
may be roundish, acuminate, globoid, conical, umbilicated, sur- 
rounded by an inflamed or normal integument; may be super- 
ficially or deeply seated; may terminate by rupture or desicca- 
tion; may or may not be followed by an ulcer and ultimate 
cicatrix. They may be seated either upon the free surface of 
the skin, or at the orifice of a follicle, in which case they repre- 
sent an inflammation with purulent product in the duct or gland 
beneath. 

Pustules are seen in syphilis, variola, eczema, scabies, acne, 
and many other cutaneous diseases, including several forms of 
dermatitis medicamentosa. 

Excoriations are superficial solutions of continuity, usually 
involving portions of the skin affected with pruritus, and 
resulting from mechanical violence. 

Excoriations, in appearance among the most trivial of skin 
lesions, possess a value from the diagnostic standpoint which can 
scarcely be overestimated. They occur as striated, linear, punc- 
tate, circular, or irregularly shaped furrowed wounds, at times 
involving areas of flat surface, oozing with serum or blood, cov- 
ered with dried blood or crusts, yellowish or reddish in hue, and 
for the most part both induced and accompanied by severe pru- 
ritus. They may coexist with hyperemia and infiltration of the 
skin beneath, brought on by the irritative character of the con- 
tinuous, or more frequently interrupted cause by which they 
were begotten. 

Excoriations become significant according as they indicate 
scratching, tearing, or other species of wounding by the finger 
nails, and rubbing portions of the integument with foreigu 



LESIONS AND LESION-RELICS. 51 

bodies. Tn the former case they are significantly recognized in 
those portions of the body most accessible to the hands, though 
in the case of eczematoos children and infants they may origi- 
nate by the rubbing together of the knees ; or the leg of one side 
by the feet and toes of the other. The loss of tissue may extend 
deeper than the rete, — at times invading the papillae of the 
corium, which bleed in consequence. 

Excoriations may occur without the appearance of other 
lesions, as in the disease called pruritus; but where itching is 
severe and induced by a cutaneous exanthem, the lesions con- 
stituting the hitter may be intermingled with, obscured, or 
even obliterated by excoriations and the pathological processes 
to which they give origin. Thus maculae, vesicles, pustules, 
and papules may undergo change ; and the recognition of 
the type of the existing disease be correspondingly difficult. 
Excoriations are common in skins wounded by lice, bed-bugs, 
and gnats; in the subjects of eczema, scabies, intertrigo and 
prurigo; and in individuals with special sensitiveness of the 
integument to the action of a medicament employed either inter- 
nally or externally. 

Fissures, or rhagades, are linear solutions of continuity, 
usually occurring in previously infiltrated portions of the 

SKIN. 

They may extend to the derma, and even invade yet deeper 
structures; may be painful, or the reverse; dry, secretory, or 
incrusted; are often hemorrhagic, and usually formed with 
sharply-cut walls. They are- of frequent occurrence in the vi- 
cinity of the articulations, in which situations they are in- 
duced or aggravated by the joint-movement, stretching or tear- 
ing tissues whose extensibility has been diminished by any 
morbid process. Fissures may terminate in ulceration. They 
are for the most part lesion relics; and are observed in syphilis, 
eczema, psoriasis, and dermatitis. 

Scales, or squamae, are attached or exfoliated epithelial 
lamellae, which have become appreciable at the surface as 
the result of some morbid process in the skitf. 

A physiological desquamation is constantly in progress over 
the superficies of the body, whose evidences are not pronounced 
in skins properly cleansed by ablution. In disease processes, how- 
ever, desquamation may occur as a distinct symptom in various 
forms. Thus the scales may be minute, fine, branny, dirty-white, 
or yellowish ; they may be larger, pearly-white, shining; dry or 
fatty; aggregated so as to resemble flaky pie-crust; exfoliating 
in extensive sheets, as from the entire sole of the foot or palm 
of the hand ; or in glove finger-like sheaths, as from the surface 
of a digit. They may be scanty, scarcely perceptible, and so 



52 GENERAL SYMPTOMATOLOGY. 

attached as to require force for their removal ; they may fall 
spontaneously in a pulverulent shower, being so abundant as to 
till the garments or bed-clothing of the patient. 

Furfuraceous desquamation is that form in which fine bran- 
like scales are shed from the surface. 

Scales occur in eczema, psoriasis, pityriasis, ichthyosis, syph- 
ilis, and iu several of the parasitic diseases of the skin. 

It should not he forgotten that scales are frequently inter- 
mingled with other lesions, often they succeed the latter, ami 
become lesion-relies. Thus a papule may scale at its apex, or 
surround its base with a collarette of loosened epidermal plates, 
beneath or between which a macular stain is visible. Again, 
they may develop from the macule, the tubercle, or the tumor. 
Though generally conceded to be evidences of a dry and non- 
discharging disease of the skin, they are at times accompanied 
or succeeded by moisture of the part affected. 

The term " scales" is sometimes applied to the flattened plates 
of dried sebum which form on the scalp and portions of the trunk 
in seborrhcea sicca. 

Crusts upon the skin are relics of the desiccation of its 
pathological products. 

Crusts are of the number of true lesion-relics, never occur- 
ring as primary symptoms of disease. When formed by the 
desiccation of serum only they are of a yellowish, straw-yel- 
lowish, or reddish-yellow hue; when composed largely of dried 
pus they are colored greenish, or greenish-yellow; and, when 
there has been an admixture of blood, they are usually brown- 
ish or blackish. At times they suggest in appearance gum, 
honey, or Venice turpentine; in shape they may have the form 
of the concavo-convex lid of a watch-case; in color and shape 
they may resemble the half-shell of the oyster, or the cara- 
pace of a small turtle. They may be delicate and thin; bulky 
and thick ; friable or mealy ; may be firmly attached to the sub- 
jacent tissues, or readily separable; may cover a sound, though 
tender and reddened epidermis; may conceal a superficial, or 
deep, foul-based ulcer, by whose secretions from beneath they 
are raised above the plane of the skin and increased in thick- 
ness. They may be circumscribed and no larger than a small 
finger-nail ; may envelop an entire limb or organ, as the leg or 
the penis; or, finally, may be so irregularly disposed among 
other lesions, papules, pustules, excoriations, and open ulcers, 
that it is difficult to define their outline, and even to recognize 
ther identity. Crusts formed of dried sebum are greasy to the 
• touch, dirty-yellowish in shade, and usually seated upon a non- 
infiltrated base. Crusts are common in eczema, syphilis, leprosy, 
seborrhcea, and a large number of other diseases of the integu- 
ment. 



lesions and lesion- relics. 53 

. Cutaneous ulcers are losses of substance resulting from 
a previous pathological process involving the derma, and, 
IN cases, the subcutaneous tissue. 

Ulcers also are true lesion-relics. They differ greatly in size, 
shape, color, edges, base, career, and, indeed, in all their charac- 
teristics. Every ulcer has an outline, base, floor, edges, and secre- 
tion. The outline may be circular, crescentic, reniform, ovoid, 
serpiginous, or with horse-shoe-like contour. The base, or un- 
derlying tissue, may be soft, supple, indurated, or in a state of 
active inflammation, with consequent infiltration. The floor 
may be glazed, shallow, deep, excavated, cup- or funnel-shaped, 
"worm-eaten," crateriform, sloughy, covered with a tenacious or 
readily removed secretion, granular, puriform, or hasmorrhagic. 
The edges may be clean-cut, having a punched appearance, un- 
dermined, everted, ragged, regular, or contracting, with a whitish 
inner border of advancing cicatrization. The secretion may be 
scanty, limpid, puriform, profuse, ichorous and odorless, or ex- 
haling an offensive stench. They may be so crust-covered as to 
be invisible, or so exposed and. erosive in action as to render the 
affected surface in the highest degree unsightly. They may be 
acute or chronic, insensitive or productive of intense pain ; may 
heal by cicatrization, remain open for a lifetime, or prove fatal 
by either destruction of parts essential to life, or by exhaustion 
of the vital forces. 

Scars, or cicatrices, are new formed substitutes for lost 
connective tissue. 

Scars are essentially lesion-relics. They never succeed, ex- 
coriations, fissures, or other solutions of continuity in the 
skin, which have not penetrated, as far as the derma, and 
resulted in destruction of a portion of the elements of which 
the latter is built up. They possess the highest importance 
for the diagnostician, since they point invariably to a patho- 
logical process whose career is terminated, the characteristic 
features of which they frequently embody. They may be re- 
garded as the special and persistent imprints upon the integu- 
ment of the serious disorders from which it has suffered. 

To a certain extent, as already intimated, scars retain traces 
of the special peculiarities of the lesions, and even of the dis- 
eases, which they succeed. The identification, however, of the 
individual predecessor in each instance is, in the present state 
of our knowledge, not always possible from a study of cicatrices 
alone. The extent of knowledge in this direction is, however, 
rapidly increasing, and in many cases the certainty thus acquired 
is of incalculable value to the diagnostician. 

Scars are remarkable for their tendency to contraction and 
gradual decoloration. They may be minute, punctate, extensive 
in area, attached to underlying tissues, depressed, raised above the 
plane of the peripheral skin, seamed with furrows, pliable and 



54 GENERAL SYMPTOMATOLOGY. 

soft, indurated, traversed by ridges, knotted, and as irregular 
in contour ns the ulcers already described. They may extend 
in digital, linear, or annular prolongations toward contiguous 
portions of the skin, and by subsequent contraction induce con- 
siderable distortion and deformity. Thus they may drag down 
an eyelid, and ectropion ensue; may glue the lobe of the ear to 
the cheek ; may evert lip or nostril. When recent, they are 
usually reddish in tint ; when older, be pigmented in centre or 
circumference, or, as is common, exhibit a gradual decoloration, 
centrifugal in its progress. They may be the seat of pain from 
an entrapped nerve-filament ; may reopen to ulceration, or be 
accompanied by no subjective sensation. Not rarely they be- 
come the origin of the disease known as keloid. Scars are 
unprovided with hairs, papillae, or the orifices of sweat and 
sebaceous gland ducts. As implied in the definition given 
above, scars may result from any disease or injury of the skin 
which involves loss of connective tissue elements in the corium. 
In addition to the names of the lesions of the skin just 
enumerated, certain peculiarities of cutaneous symptoms are 
described in qualifying terms, which here require definition. 
They relate chiefly to the color, shape, distribution, and method 
or period of evolution of lesions as they are observed in individ- 
ual' cases. The more important of these terms, as used by 
modern writers, are arranged below, alphabetically, with a 
brief explanation appended to each. A much larger list of 
obsolete adjectives, employed by older authors, is purposely 
omitted. 

Abdominalis. Located on the abdominal surface. 

Acumixatcs. Having a pointed apex. 

Acuttjs Of acute course. 

Aiultorum. Occurring in adult years. 

^EsriVALis. Occurring in the season of summer. 

Aggregatus. Collected in patches. 

Agbiub. Acute, or angry in appearance. 

Albidus. Of whitish color. 

Annularis. In the form of a ring. 

Annulatus. In t lie form of a ring. 

Apyketicus. Unaccompanied by fever. 

Areatus. Occurring in anas. 

AhtIficialis. Producible artificially. 

Asymmktricalis. Of different distribution on the two lateral halves of the 
body . 

Autumxaris. Occurring in the fall of the year. 

Buachiaeis. 'Occurring on the surface of the arm. 

CachECTICORTJM. Occurring in debilitated subjects. 

Capitis Occurring on the head, usually the scalp. 

CHRONICUS. Chronic in course. 

Circinatus. Of circular outline. 

Circumscuiptus. Having a definite contour. 

CONFERTTJS. Arranged in close proximity, with coalescence of lesions. 

Coxflcens. Arranged in close proximity, with coalescence of lesions. 

Contagiosus. Capable of communication by contagion. 

Corporis. Occurring on the surface of the body ; employed usually to desig- 
nate an eruption upon the trunk, as distinguished from that on the head or 
extremities. 



GENERAL SYMPTOMATOLOGY. 55 

Dippdsus. Irregularly disposed. 

Discretus. Having isolated lesions. 

Disseminatus. Disseminate, without regularity of distribution. 

Eruption. Is used of the totality of all patches and lesions upon the person 
of one individual. 

Erythematosus. Having a reddish blush. 

Exfoli\tivus. Having a tendency to exfoliation or shedding from the surface 
of the body. 

Exulcerans. Is employed by French writers to designate superficial ulcera- 
tions, or lesions with a tendency to such a process. By English and Ame- 
rican authors it is used to designate unusually deep ulcerations. 

Facialis. Located on the face, usually as distinguished from the scalp. 

Febrilts. Accompanied by a febrile process. 

Femoralis. Occurring on the surface of the thigh. 

Fibrosus. Composed of fibrous tissue. 

Figuratus. Having a figured appearance. 

Flavescens. Of yellowish hue. 

Foliaceus. Resembling a leaf or leaves. 

Guttatus. Of the size of a drop of water. 

Gyratus. Having a serpiginous or gyrate outline. This is usually the result 
of a coalescence of imperfect circles or semicircles. 

Hismalis. Occurring in the winter season. 

Humidus. Accompanied by moisture. 

Hypertrophicus. Characterized by hypertrophy. 

Infantilis. Occurring in infancy. 

Intertinctus. Distinguished by color. 

Iris. Occurring in more or less distinctly defined concentric rings. 

Labialis. Occurring upon the surface of the lip. 

Lenticularis. Of the size of a small bean. 

Madidans. Characterized by moisture. 

Marginatus. Having a defined margin. 

Medicamentosa Produced by external or (more commonly) internal medi- 
cation. 

Melanodes Of blackish color. 

Miliaris. Of the size of a millet seed. 

Mitis. Of mild, benignant type— the reverse of agrius. 

Multiformis. Exhibiting simultaneously several types of elementary lesions. 

Neonatorum Occurring in the newborn. 

Nigricans. Of black or blackish color. 

Nodosus. With development of nodes or tuberosities of the surface. 

Nummularis. Of the size of small coins. 

Olecsus. Accompanied by an oily secretion. 

Palmaris. Occurring on the palms. 

Parasitarius. Produced by an animal or vegetable parasite. 

Parasiticus. Produced by an animal or vegetable parasite. 

Patch. The aggregation of several isolated or confluent lesions. 

Pigmentosus. Accompanied by pigmentation. 

Pilaris. Related to the hair. 

Plantaris. Situated on the soles of the feet. 

Planus. Flat. 

Polymorphous This is the Greek equivalent of the Latin multiform. 

Pr^eputialis. Situated upon the prepuce. 

Progenitalis. Situated on the exposed mucous surfaces of the genitalia. 

Pruriginosus. Accompanied by itching. 

Pubis. Located upon the skin or hairs of the pubis. 

Punctatus. Occurring in dots or points. 

Rosaceus. Having a rosy or pinkish hue. 

Ruber. Red, usually dark red in color. 

Scutiformis. Having the shape of a shield. 

Senilis. Occurring in advanced years. 

Serpiginosus. Literally, creeping — advancing in irregular gyrations. 

Siccus. Dry, unaccompanied by moisture. 

Solitarius. Having an isolated lesion, or with isolated lesions. 

Symmetricalis. Similarly distributed on the two lateral halves of the body. 



56 GENERAL ETIOLOGY. 

I'niiokmis. Exhibiting lesions all of one type. 
I'mvkksai.is. Affecting the entire surface of the body. 
VaRIEGATTJS. Exhibiting several distinct colors. 
Vasi dlosus. Accompanied by vascular development. 
Vernalis. Occurring chiefly in the spring of the year. 
Versicolor. Exhibiting Beveral shades of the same color. 
Yi i G \jiis. Of the usual or commonly observed type. 



III. 

GENERAL ETIOLOGY. 

The study of the causes of diseases of the skin ogives us a 
glimpse of the etiology of diseases in general. In the lowest 
representatives of life, the greatest dangers to existence origi- 
nate in exposure to assault from other and stronger representa- 
tives in search of their prey, in other terms an external danger. 
In man, the highest representative of the animal scale, the perils 
of existence are complicated hy his social necessities and his arti- 
ficial methods. He can never, however, at any period of his 
existence, divest himself from the necessity of exposure to exter- 
nal peril. The plan of his organs and the play of his normal 
activities are perfect, even to the recovery from all hut mortal 
injury and the repair of moderate loss. The struggle for exist- 
ence of the ideal man is intended to he with that which is with- 
out ; his body meanwhile furnishing him with a comfortable 
tenement and a fair fortress. In the purview of nature there 
should he no internal revolt. When such occurs, it is usually 
the result of his ignorance, his folly, or his vice. 

Viewed in this light, the causes of the diseases of his skin 
will be seen to differ but little from those which induce disease 
in his other organs. Exposed to cold, he suffers from a pneu- 
monia ; to injury, a fracture or a dislocation ; to the contact of 
poisons, lie vomits or purges; to contagion from his fellow-man, 
lie has the cholera or plague; all these are capable of producing 
diseases of his skin. But meantime his organs have a tender 
care for themselves and each other, compared with which the 
solicitude of a mother for her child becomes insignificant. The 
stomach refuses to digest itself; the lung, unwounded, admits 
no air to the pleura ; the bladder, so long as it is unruptured by 
violence, permits no drop of urine to pass into the peritoneal sac. 
In the same proportion and under the same general law, do the 
viscera refuse to generate a poison which will injure the integu- 
ment; and the fluids of the body, a vicious u humor" which 
will damage the bones. 



GENERAL ETIOLOGY. 57 

Reasoning thus from analogy alone, it will be seen that the 
prevalent doctrines respecting blood-poisons of internal origin 
must be greatly restricted. Eczema alone, in its manifold forms, 
furnishes more than one-half of all the diseases of the skin ; and 
yet every one of these several forms can be produced at will and 
artificially upon the integument of man. 

Again, it is not to be forgotten that the body is really invested 
with a continuous skin which not only is extended over its 
outer surface, but is also reflected so as to line all passages by 
which it is traversed within. This inner investment, called the 
mucous membrane, is as truly a part of the skin as the epider- 
mis and corium of the face or hand. This is clear: first, as 
shown from the facts of evolution, because representative ani- 
mals of the lower scale are found capable of complete inversion, 
by which the outer skin becomes the inner or digestive, and the 
inner, in turn, the outer or protective organ; second, as shown 
by histology, the anatomical characters of the skin and mucous 
membrane being similar; third, as shown by pathology, the ex- 
troverted mucous membrane rapidly undergoing the transforma- 
tion which causes it to resemble the skin ; while the inverted 
skin, as when the thighs are by disease kept in continuous con- 
tact and moistened, assumes the characteristic features of mucous 
membranes. In the study of cutaneous etiology, it is manifestly 
proper to regard as of external origin all causes which operate 
from without upon either the outer or the inner skin of the body. 

This much premised, it can be said that the large proportion 
of all diseases of the integument originate either from the ac- 
tion of solar heat and light ; temperature changes at the surface 
of the body; contact with various fluid and solid substances 
with the production of either frictional, traumatic or toxic 
effects; or the development upon and within the skin, of vege- 
table parasites. It remains merely to consider these causes 
somewhat in detail, remembering that at times several influences 
cooperate in the production of a given effect. 

The action of solar light upon the skin is usually coincident 
with the operation of another mode of motion called heat. To 
the former are to be attributed the production of freckles, " tan," 
and other pigmentations of the surface; to the latter, the ery- 
thema, eczema, and various grades of dermatitis which may fol- 
low exposure to the direct rays of the sun. Other temperature 
effects, including those produced by extremes of both heat and 
cold, are to be classed in the same category. According to ITebra, 
exposure of the skin to a temperature over one hundred degrees 
Fahrenheit, produces merely a transient erythema, which under 
a further elevation of sixty-five (65° F.) degrees will not subside 
for several days. At a temperature of two hundred and twelve 
(212° F.), all grades of acute dermatitis are awakened with the 
production of bulla?, up to the point where complete destruction 
of the integument occurs. 



60 GENERAL ETIOLOGY. 

integument, and conic in contact with toxic agents, without 
exhibiting a disease of the skin. Often there is a marked decree 
of sensitiveness of the integument peculiar to the individuals 
who suffer, which may exhibit itself in several members of one 
family, or exist in one person for hut a hrief period of time. 
Again, an individual idiosyncrasy may he exhibited, in conse- 
quence of which an article, harmless to all others, becomes to 
him alone a source of serious discomfort. 

The various physiological changes of the human body are 
never the causes of diseases of the skin, hut at times furnish 
special opportunities for the operation of such causes. Thus in 
the rapid tissue evolution of early life, eczema and lupus are 
relatively common — carcinoma and tinea versicolor rare. At 
puberty the hairs of the heard of the male are liable to the 
incursions of the trichophyton; and the nipple and breast of the 
female become the seat of eczema from epiphora of milk. The 
old man and the old woman may become the victims of cancer, 
aggravated forms of pruritus, and horny growths. Dentition, 
menstruation, pregnancy, and the menopause disturb the physi- 
ological equilibrium, and at times render the access of other 
disturbing forces exceptionally facile. The sexual appetite leads 
to excesses which bear fruit in attacks of herpes, pruritus, and 
syphilis. And the unceasing excretion from the skin surface, 
with constant deposit there of effete material, may, when there 
is prolonged disregard of the laws of cleanliness, induce a lia- 
bility to disease of the skin which is especially marked in the 
case of infants and children. 

The power to transmit skin disease by heredity is of less im- 
portance than is generally supposed. It is most conspicuous in 
the instances of hereditary syphilis; but even here the trans- 
mission of the disease is not without singular exceptions, and is 
limited to certain periods of the disease in the progenitors. The 
transmitted disease is also most, common in the foetus, which is 
in direct communication with the mother, and rapidly dimin- 
ishes in frequency with every month of separate existence, till 
late and very late instances of hereditary syphilis have come to 
be received with suspicion. Many of the examples cited of 
hereditary transmission of cutaneous diseases are, without doubt, 
cases of coincidence, which, considering the number of patients 
affected annually with eczema and psoriasis for example, should 
not be regarded as of very rare occurrence. 

The list of causes recognized as directly productive of dis- 
eases of the skin are, without question, under special circum- 
stances, capable of operating as indirect etiological factors. 
Temperature changes, contacts Avith the external world in all 
harmful degrees, and toxicants are prime agents in the produc- 
tion of diseases of internal organs; and these in turn may in- 
duce changes in the skin of the nature of disease. The uterus, 
the stomach, the liver, the kidney, the heart, the nervous ceu- 



GENERAL DIAGNOSIS. 61 

tres, and the intestinal tract may become disordered, and the 
result be declared not only in disturbance of the function of 
these organs, but in an attack of urticaria, pruritus, jaundice, 
or erythema. Passive congestions of the surface, leading to 
oedema and violaceous blush of the skin, often result from circu- 
latory changes ; and, in fine, any constitutional disease, by im- 
pairing general nutrition, arresting repair, hastening waste, or 
in other directions impoverishing the protoplasm of the body, 
is capable of inducing disorder in the skin as in other organs. 
Thus in cancer, chlorosis, anaemia, and cholera there are signifi- 
cant alterations in the hue of the integument which possess not 
merely a diagnostic value for the clinician, but attest the sym- 
pathetic unity of each organ of the body with all others. 



IV. 
GENERAL DIAGNOSIS. 

The establishment of an accurate diagnosis in a cutaneous 
disease is essential to its successful management. This state- 
ment is rendered necessary in this connection by the preva- 
lence of a belief among the uneducated that the disorders 
of the skin, exhibited for the most part in visible symptoms, 
can be safely treated on general principles, without a recog- 
nition of the nature of the malady. By many practitioners the 
demand for an accurate diagnosis is ignored in consequence of 
a too general impression that the desired end is to be pursued 
through great and perplexing obscurity. Yet with patience, 
method, a habit of careful observation (without which no 
physician is successful), and a reasonable degree of skill, both 
the practitioner and student can attain their purpose in the 
large proportion of all cases. 

It is a popular error that the sole requisite for establishing a 
diagnosis is the exhibition of the affected portion of the integu- 
ment to the eye of him who is consulted with a view to its 
relief. The physician is supposed to inspect this surface at- 
tentively for a few moments, and then to pronounce definitely 
upon the nature of the disease present and the therapeutic 
measures to be adopted. But far more than this is requisite, 
and, indeed, fully as essential here as in the investigation of a 
disease involving any other organ of the body. 

It is first necessary to secure a history of the physical and 
mental condition of the patient in the past ; then should follow 
the special history of the disorders of the skin; lastly, an 



62 GENERAL DIAGNOSIS. 

examination of the affected integument. For the purpose of 
methodically arriving at these facts, and of preserving them 
tor future reference, they should he systematically recorded. 
The following are some of the points upon which it will gene- 
rally be found useful to secure information : — 

The name, residence, age, sex, occupation, and married or 
unmarried state of the patient should be known, as also, when- 
ever practicable, the health-history of parents and children. In 
the case of women it is not only necessary to learn of the per- 
formance of the menstrual function in the past, but of the 
highest importance to he informed as to the previous occurrence 
of abortions and miscarriages, and, if such have occurred, the 
order observed by these with relation to the birth of viable 
infants. The significance and value of several of these facts 
have been described in the chapter on etiology. With respect to 
the history of the products of conception, it should never be 
forgotten that these have a most important bearing upon the 
question of syphilitic infection ; and the absolute exclusion of 
syphilis in any obscure case is a long step in the direction of 
an accurate diagnosis. In the case of male patients, questions 
will usually elicit either admission or denial of the fact of a 
precedent or present venereal disease, and the answers should 
be recorded as valueless or trustworthy according as they are or 
are not substantiated by corroborative clinical facts. 

Then should follow some record of the habits of the patient, 
as to active or sedentary employment, bathing, food and drink, 
including under the latter term the use of beer, wine, and 
spirits. The history of any previous disorders, whether of the 
skin or other organs, should be satisfactorily clear ; and, with 
respect to the latter, the dates of occurrence, recurrence, and 
convalescence be at least approximately discovered. The patient 
should also make known whether he has had refreshing sleep; 
whether he lias undergone mental anxieties (domestic, financial, 
etc.); whether he has suffered in his digestive, respiratory, cir- 
culatory, gen i to- urinary, or nervous system. 

This much ascertained, the patient should be encouraged to 
narrate as succinctly as possible, and as far as may be in his 
own terms, the history of the present cutaneous disorder. He 
should give the subjective sensations it has produced, as also 
the objective features presented to his own vision and touch. 
In the case of infants this information will of course have to be 
obtained from the mother or nurse. The treatment to which 
the disease has been subjected should then be detailed. This 
frequently furnishes a key alike to the diagnosis and therapy 
of the disorder. In an incredibly large proportion of all cases, 
ignorantly directed and vicious internal or external medica- 
tion has either begotten or aggravated the disease of the skin. 
This much ascertained, the physician is ready to examine the 
affected suriace for himself. 



GENERAL DIAGNOSIS. 63 

During, however, the verbal interrogations which are required 
for this first part of the exploration of the case, the watchful 
and observant practitioner will probably have secured for him- 
self some useful information of which the patient is totally un- 
conscious. Much of this is difficult to describe, as it is the rich 
fruit of a wide experience and careful scrutiny. With a gentle, 
courteous, and sympathizing manner, the diagnostician must 
combine the art of a detective and the skill of a swordsman. 
Glancing occasionally at the face of his patient while making 
record of the answers given, he will of course have observed 
any eruption upon that portion of the body. lie will have 
made a mental note of the temperament of the sufferer, or any 
movement made by the latter indicating a tendency to scratch 
or rub any portion of the skin. He will have noticed the 
posture, clothing, and head apparel ; the existence of hair on 
the scalp or extensive baldness; the condition of the exposed 
hands, as indicating manual labor or the reverse ; and, in the 
absence of facial lesions, will have observed the general tint of 
the skin of the face, as indicating anaemia, chlorosis, or a gen- 
eral condition of cachexia. The facial expression, as indicative 
of anxiety or placidity, habits of debauch, sexual excesses, etc., 
will not have escaped his attention. All this and much more 
will have possibly enabled the questioner to direct his inter- 
rogatories into the channel where they would elicit the most 
useful responses. The posture, cries, facial expression, and gen- 
eral condition of nutrition of the infant will have been no less 
carefully noted. 

Proceeding to the examination of the affected integument, 
the physician must assure himself of a good light, as colors are 
best distinguished by daylight, and artificial illumination should 
be reserved for exploration of the cavities of the body. The air 
of the apartment should be sufficiently warm to permit of ex 
posure of the person without discomfort. Adult males and 
children of both sexes should have the clothing completely re- 
moved, so that all portions of the skin may be inspected. One 
portion of the body may, however, be examined, and then re- 
covered, if desired, while the examiner proceeds to direct his 
attention to another. In the case of women the investigation 
should be conducted with all the tact and delicacy to which the 
sex is entitled. 

The examination, whenever practicable, should extend over 
the entire surface of the integument. The importance of this 
point can be scarcely exaggerated. It must be remembered that 
the physician should be very much wiser than his patient ; and 
the assurances of the latter are always to be accepted with re- 
serve. Thus one who exposes his leg merely, stating that this 
is the only part of his body affected, may have concealed be- 
neath his clothing extensive varicosities of the veins of the thigh, 
a typical syphilitic exanthem over the belly, a significant scar 



64 GENERAL DIAGNOSIS. 

on his elbow, an extensive patch of tinea versicolor on the sur- 
face of the chest, or a blennorrhagic discharge from the urethra, 
the medication of which has induced the rash for which he seeks 
relief. These are not the rare, but the common cases of a daily 
experience. 

Observation should be had at this time of the general and 
special features of the eruption. As to the former, the following 
considerations should be borne in mind : — 

A symmetrical eruption, one equally distributed over the two 
lateral halves of the body, is rarely the result of an etiological 
factor operating upon the outer skin. It more often points to an 
efficient cause of so-called internal origin, one influencing the 
inner skin or the internal organs. An eruption affecting the 
covered integument, never creeping out upon the exposed sur- 
faces, suggests the operation of the clothing; as the latter may 
chance to prove the nidus or protector of a parasite, the fabric 
which has been colored by a noxious dye, the recipient of a 
chemically-altered secretion, which has proved irritating to the 
surface, the instrument of friction, or the source of increased 
temperature at the surface by its non-conductivity of heat and 
unseasonable thickness. An eruption, accompanied by excoria- 
tions and scratch-lines, is that usually most severe in the parts 
most accessible to the hands, and least developed where the latter 
have the least ['lay, as over some parts of the back. An eruption 
limited to the hands is likely to be one induced l>y an agent to 
which the hands alone have been exposed, as those originating 
in the trades and domestic occupations; while in the latter, an 
eruption more distinct on the right hand, and especially about 
the right thumb and index finger, tells its own story when the 
hand-worker is not ambidextrous or left-handed. Artificially 
and intentionally produced eruptions, as in malingering, hys- 
teria, mental depravity and insanity, usually occur also in parts 
to which the right hand finds easy access. 

Eruptions occurring on the face, hands, and genitalia of the 
male, or face, hands, and mammae of the female, point to exter- 
nal contact or contagion (poison-ivy, scabies, croton-oil, etc.); 
since, next to the face, the hands are more commonly brought 
in contact with the parts named in the sexes respectively, as 
the wearing apparel of each suggests. 

An eruption, limited to the forehead, suggests an inspection 
of the hat-hand, the veil, or the overlying false hair; to the 
ears of the female, a glimpse at her possibly cheap ear-rings; to 
the centre of the root of the neck, before or behind, a scrutiny 
of the collar-buttons and collars; to the anus of the baby, an 
inquiry as to the changing of its napkins; to the wrists of the 
adult, a question as to the cuffs worn ; to the feet, information 
respecting gaiters, varicose veins, recently cut corns, and ill- 
fitting shoes. Eruptions springing from each of these causes 
have been long and vainly treated as " diseases of the blood." 



GENERAL DIAGNOSIS. 65 

Eruptions markedly asymmetrical are indicative of asymmet- 
rically operating causes — that is, the accidents of the outer world 
contact, or else influences exerted within the body unequally 
on its two lateral halves. Thus an orthopaedic apparatus, worn 
to correct talipes, excites an eczema in the affected leg only ; 
and zoster of the trunk is evident on that side supplied by the 
intercostal nerve which has been inflamed. The greater stress 
may be laid on this peculiarity, as the law of symmetry, in erup- 
tions not occasioned by causes operating on the outer skin, is 
faithfully observed in nature. The earlier syphilides, the qui- 
nine exanthem, rubeola, and even lupus erythematosus, are 
remarkable illustrations of this fact. 

Proceeding next to the special visible characteristics of the 
eruption, the physician will not fail to note an acuteness or 
chronicity of lesions; their color, size, distribution, tendency 
to become aggregated in patches, or the reverse ; and the evi- 
dence presented as to change in type, the sequence or coexistence 
of several lesions at the same time,— that is, the multiformity 
(polymorphism) or uniformity of the eruption. He will observe 
whether the limit of the affected skin is well-defined against 
that which is normal, or scarcely to be outlined with a pen or 
pencil. He will rupture a bleb, pustule, or vesicle, should such 
be found, to discover the nature of its contents. He will re- 
move one or several crusts in sight, to expose the surface on 
which they rest. He will remove a few scales with the dermal 
curette for a similar reason. He will as carefully inspect the 
skin where the disease has existed, as that where it does exist. 
He will pinch up between his thumb and finger a small portion 
of each, in order to determine its infiltrated condition ; its 
atrophy ; or its attachment to the tissues beneath. He will pass 
his hands over the surface to recognize the firmness or softness 
of the lesions, their dryness or moisture, and the existence of 
sebaceous or perspiratory secretion. He will look at the mouths 
of the follicles, where such secretion is retained or abund- 
antly exuded. He will discover any ova or lice on the hair; 
any ascarides at play about the anus ; any unnatural forma- 
tion of the nail, or deformity of its matrix. He will examine 
for inguinal, post-cervical, axillary and epitrochlear adenopathy, 
and will thus be often greatly aided in his task. This done, he 
will question in turn for himself, and by the methods recognized 
in medical science, the organs of the body other than the skin. 
He will inspect the tongue carefully, and then, if he is through 
with the mouth, he will be guilty of great error. The gums 
rarely deceive the questioning eye; the inside of the lips, fauces 
and tonsils are all to be searched. A mucous patch here will 
often echo the story of a palmar or plantar syphiloderm. The 
laryngoscope may be called for in syphilis, cancer, lupus and 
leprosy. The degree of distension of the belly, and the region 
of hepatic dulness, should not be overlooked. The genitalia of 
5 



66 GENERAL DIAGNOSIS. 

the male, and of children and infants, can usually be explored. 
For women unaffected with syphilis or disease limited to these 
parts, an exception in this particular should usually be made. 

With the necessary reserve of all very obscure cases, it may 
be said that the diagnostician who has conscientiously con- 
ducted an examination after the manner described above, is in 
possession of the diagnosis for which he seeks. If the facts thus 
acquired have been properly recorded, and yet do not spell out 
the diagnosis to his eyes, they are probably legible to others 
with a wider experience or riper judgment, to whom such a 
record is shown. It is not claimed that this exhaustive method 
of examination is requisite in every case, as, for example, in 
order to recognize an acne or to differentiate erysipelas from 
erythema. But it is certain that few obscure cases of skin 
disease will remain such under severe scrutiny, and the estab- 
lishment of a thorough and exhaustive method of examination 
is important in the earliest experience with disease. Let the 
student or practitioner conduct such an examination in the first 
few cases of eruption upon the surface of the body for which 
his advice is sought, and he will establish a habit of observa- 
tion in comparison with which his pecuniary or professional 
success in the management of the same cases will be indeed of 
trivial worth. 

Upon one special point should the inexperienced physician be 
guarded. It relates to the acceptance of a diagnosis which is 
not based upon such an examination as that given in outline 
above. The diagnosis of a patient is usually faulty, and the 
verdict of even skilled practitioners may be founded upon an 
error. The careful diagnostician should commence his task in 
a spirit of skepticism, and pronounce definitely only upon 
ascertained facts. The man who says he has an " eczema" 
ma} T be louse-bitten; the woman who has been "overheated" 
may prove syphilitic. The patient recognized as suffering from 
ringworm of the heard may not have been infected under the 
hands of the barber. Finally, the eruptions upon patients un- 
mistakably syphilitic are often of other than syphilitic origin. 
They are men, women, and children exposed daily to the acci- 
dents from which the non-infected suffer. They exhibit acne, 
physiological alopecia, and dermatitis medicamentosa equally 
with those who have not sinned sexually. 

For the diagnosis of special diseases of the skin, the reader is 
referred to the chapter in which each is considered. 

The microscope is an instrument whose aid in establishing a 
diagnosis of cutaneous disease can rarely be dispensed with. 
The contributions it has made to the knowledge had on the 
subject of pathology are of inestimable value ; and as a means 
of diagnosis it can be used with advantage both at the time of 
the first examination of a patient, and afterward for the more 



PROGNOSIS. 67 

leisurely examination of hairs, scales, crusts, or portions of 
tissue. Those unable to secure the costlier and elaborate in- 
struments sold by the makers, should take pains to provide 
themselves with a fairly good "student's stand," and a fifth and 
half inch objective for diagnosis in skin diseases. 



V. 
PROGNOSIS. 



The prognosis of most diseases of the human body is formu- 
lated with a view to the decision of the serious question of life 
or death. Occasionally this question arises in connection with 
skin diseases. Many of the latter are trivial ; some are grave ; 
a few, inevitably fatal in their termination. Thus general ex- 
foliative dermatitis, leprosy, myeloma, carcinoma, at times 
lichen ruber, and variola in the unprotected, are of grave por- 
tent ; while the ordinary hypenemise and exudations, the great 
majority of all cases of acquired syphilis in adults, and the 
entirely curable diseases induced by parasites do not excite 
alarm in the breast of the average patient with respect to his 
longevity. 

The questions, however, as to his future, which are urgently 
pressed by the victim of cutaneous disease, are both numerous 
and important. He is anxious as to the time during which he 
must suffer; as to the possibility of conveying his disease to his 
progeny or other members of his family; as to the disfigure- 
ment of his person which might result; as to the scars which 
he may have to carry for the remainder of his life; as to the 
possible recurrences of his malady in the future. The responses 
to these questions will be largely influenced by the prognosis 
of the physician. 

Some diseases of the skin are acute, rapidly pursue their 
course, and are then prompt to disappear. Others are chronic, 
rebellious to treatment of the most energetic and skilful char- 
acter. Others, again, though not shortening life, are never re- 
lieved while life is continued. Some disappear, only to reappear 
at more or less regular intervals. There are cutaneous diseases 
which affect one individual but once in his lifetime; others 
which reappear at the instant the patient is again exposed to 
their exciting cause. There are cutaneous diseases so distort- 
ing and destructive in their effects, that their victims have 
committed suicide under the influence of the morbid emotions 
which they have as a consequence experienced. 



68 GENERAL THERAPEUTICS. 

The mental distress occasioned by oven an insignificant cuta- 
neous disorder is often out of all proportion to its exciting 
cause; and this should always be regarded in establishing a 
prognosis. The sexual hypochondriac has been made insane by 
an acne ; and the man or woman affected with syphilis has 
been made wretched for years by a recurrent erythema. 

Again, a disease of the skin may coexist with grave lesions 
of internal organs, and the prognosis of the disease of the one 
be greatly influenced by that demanded by the other. Thus 
there is occasional coexistence of syphilis and phthisis. Pru- 
ritus may be associated with Bright's disease of the kidneys ; 
and the eczema of an infant starving for want of breast-milk 
may hasten its marasmus to a fatal termination. 

Upon the answers given to his patient inquiring as to the 
prognosis of the disease of the latter, will largely depend the 
professional success of the physician. Scrupulous honesty 
should be here welded with all the skill that science can com- 
mand. That a. disease does not endanger life, is not an argu- 
ment in favor of its amenability to treatment. The practitioner 
should never suffer himself to be pushed by his patient to the 
position that an obstinate disease is readily manageable. It is 
the height of folly to lightly estimate that zoster of the forehead, 
the scars of which the patient will exhibit to all who afterward 
look upon his face both in life and death. He who engages to 
relieve an alopecia areata in the month, may have a year in 
which to repent his precipitancy. There is no way in which 
the conscientious physician can so readily secure the confidence 
of his patient, and with it that willingness to submit to appro- 
priate treatment, which is begotten of such confidence, as by 
demonstrating his ability to forecast the future of a disease ; 
in other words, to describe accurately its prognosis. 



VI. 
GENERAL THERAPEUTICS. 

A consideration of the subject of the methods of treating skin 
diseases in general, suggests at once the intimate relation which 
subsists between the integument and other organs of the body. 
The etiology of one, largely explains the causes of the disorders 
in all. The pathological processes in each are subordinated to 
the same general laws. The principles of treatment are very 
similar, in all the disorders of the body. 

The object to be attained by treating a cutaneous disease is, 



GENERAL THERAPEUTICS. b\) 

first, its complete relief; second, where the latter is impossible, 
such a management of the morbid process as will mitigate its 
severity and render the victim of the disease more comfortable. 
A higher and more scientific achievement than either is the 
prophylaxis by which man is enabled to escape the disease alto- 
gether. He can by his wisdom largely diminish the danger to 
which his integument is exposed. He can, to a certain extent, 
shelter himself from extremes of temperature, traumatism, toxic 
agents, and the contagious diseases. He can, by observing the 
simple rules of hygiene, fortify his skin against the lesser evils 
which may befall it. If it be true that "the people perish for 
want of knowledge," it is certain that once in possession of it, 
they can greatly enhance their comfort and prolong existence. 
Here, however, the subject under consideration involves disease 
which is actually present and in progress. 

Like all other diseases of the body, those of the skin may be 
divided into three classes with relatively fixed limits. 

The first embraces all the diseases which have a natural ten- 
dency to pursue their course to a favorable termination. It em- 
braces all those affections which, either mild or severe, require 
absolutely no treatment of an active character. It is the duty 
of the skilful physician to watch the evolution of these mala- 
dies, and to discharge a most 'important duty by refraining from 
all therapeutic measures which in such cases might prove hurt- 
ful. By his judicious counsel also, he hinders patients and their 
friends from pursuing a course which might prove prejudicial 
to the disease. 

The second class embraces all those affections of the skin 
which are either inevitably fatal or hopelessly remediless while 
life is prolonged. Fortunately this includes but a small pro- 
portion of the large list. Here the duty of the physician is 
plain. He should assuage pain, attempt to relieve deformity, 
administer to the comfort of the afflicted in other ways, and, 
by his patient courage, inspire confidence and hope. It must 
not be forgotten that the skill of man has not yet reached the 
acme of human need. In the presence of many diseases of the 
body, he stands absolutely helpless ; and the speediest way to 
success in such cases is to begin by an honest admission of the 
plain fact. 

The third class of affections naturally embraces all not in- 
cluded in the other two. Here disease may be prolonged or 
shortened in its course, rendered acute or chronic, made more 
or less endurable, permitted to become inveterate, or be abso- 
lutely relieved, by prompt and energetic measures, according as 
it is, or is not, judiciously and skilfully managed. Here are 
gained the most brilliant successes of the dermatologist ; here 
also occur his most humiliating failures. 

In the presence of a cutaneous disease which requires treatment, 
a question naturally arises as to whether this treatment shall 



Hi GENERAL TH K R A PEUTICS. 

be internal, that is, by medicaments ingested; or external, that 
is, by local therapeusis ; or by a combination of the two methods 

nt the same time. With regard to the first question, which is 
one of pressing importance, it can be safely said that there are 
no remedies to be given by the mouth which can be described 
as certainly and specifically curative of the diseases of the 
skin. The number of medicinal ageuts employed with this end 
in view is incredibly large, by far the greater part being obtained 
from the vegetable kingdom. With the few exceptions given 
below, not one of these is known to exercise the slightest reme- 
dial action upon the surface of the body, though it can scarcely 
be doubted that the list will be enlarged as experiments in this 
direction multiply. Other so called remedies are, for the most 
part, utterly without value of any sort; but will continue to lie 
vaunted as specific, so long as credulity on the one hand, and 
avarice on the other, move the masses of mankind. 

The remedial agents employed internally and recognized as 
possessed of some value in diseases of the skin, are arsenic, mer- 
cury, iodine, cod-liver oil, quinine, ergot, and carbolic acid. Of 
them all, it may be said that while each possesses a wide range 
of usefulness, no one of them in any case can be certainly trusted 
to produce a given effect; and each in many cases is either posi- 
tively prejudicial or without efficacy of any kind. 

Arsenic, which properly stands at the head of this significantly 
short list, is known to exert its effects almost exclusivel}- upon 
the epithelia of the skin, and upon these, so far as therapeutic 
effects are concerned, only when they are in indolent conditions, 
subacute and chronic pathological states. It is known to exert 
an unfavorable influence upon the epidermis when the latter 
participates in a condition of active inflammation. Operating 
in this limited class of cases favorably, it also operates slowly, 
requiring months for the production of its curative effects. Its 
administration is at all times attended with the hazard of pro- 
ducing toxic effects, which, however, when the result of the ex- 
hibition of the drug in medicinal doses, are usually limited to a 
mild exanthem upon the skin, moderate coryza and some redness 
from congestion of the vessels in the eyes and eyelids. 

It is used chiefly in psoriasis, acne, squamous eczema, pem- 
phigus, and lichen ruber; its dosage in cases of children being 
relatively large. It should be invariably administered only after 
eating, and a minimum dose be first employed in order to test 
the susceptibility of the patient to its action. It should be re- 
membered that the toxic effect of this, as also of several of the 
other drugs mentioned below, is often speedily noticed after the 
first exhibition of a relatively small dose. Toleration once 
established, the dosage may be cautiously increased. 

The forms in which it is usually administered are the prepa- 
rations of arsenious acid, such as the liquor potassii arsenitis 



GENERAL THERAPEUTICS. 71 

(Fowler's solution); the liquor arsenici et hydrargyri iodidi 
(Donovan's solution); the liquor arsenici chloridi, and the 
Asiatic pill. Duhring's modification of this pill is obtained by 
making two grains (.13) of arsenious acid, and thirty-two grains 
(2.2) each of black pepper and liquorice powder, into thirty -two 
pills by the aid of a sufficient quantity of mucilage. Arsenic is 
also at times advantageously combined with other indicated 
medicinal substances, such as iron and the iodide of potassium. 
As already intimated, an unprejudiced view of its action, even, 
in cases properly selected for its administration, will justify the 
statement that it is a remedy of uncertain effect, and, in that 
proportion, disappointing. 

The value of Mercury in the syphilodermata is incontestable, 
and its injudicious employment in many cases springs from that 
precise fact. The vulgar prejudice that many disorders of the 
skin, really not syphilitic, are obscure manifestations of lues in 
a preceding generation, and amenable to mercurial treatment, 
is a striking illustration of the necessity of accurate diagnosis 
in cutaneous diseases. Few non-syphilitic affections are bene- 
fited by continuous courses of mercury, though the value of 
the metal as an alterative in this small proportion of cases must 
be admitted. The corrosive sublimate is well nigh superseded, 
in consequence of its irritative effects, by the compounds of the 
metal with iodine. The gray powder is useful chiefly in case 
of infants and children, though its not infrequent development 
of the corrosive chloride has largely limited its favor with 
Americans. Calomel and the mercurial pill should be employed 
only for transient effects, as, when administered for long periods, 
they are much more apt to produce ptyalism than the other 
preparations mentioned. 

Iodine and its compounds are also chiefly used by the derma- 
tologist in syphilitic disorders of the skin, but they possess a 
wider range of value than the mercurials in the treatment of 
other cutaneous affections. Here too the abuse of the drug fur- 
nishes the clinicien with a long list of cutaneous disorders either 
originated or aggravated by its employment. As in the use of 
arsenic, toleration should be established before large doses are 
exhibited. The compounds chiefly used are the iodides of potas- 
sium, sodium, lithium, and ammonium, and, quite recently, 
iodoform. It has been administered for the relief of the scroful- 
dermata, the two varieties of lupus, keloid, and the syphilitic 
affections of the skin. As to the latter, it may be added, that 
in the earlier skin symptoms of lues, it is often a source of 
positive injury. 

Cod-liver Oil is a remedy of special value in diseases of the 
skin, and was for that reason held in high favor by the dis- 



JO GENERAL THERAPEUTICS. 

be internal, that is, by medicaments invested; or external, tliat 
i.-. by local therapeusis ; or by a combination of the two methods 

at the same time. With regard to the first question, which is 
one of pressing importance, it can be safely Baid that there are 
no remedies to be given by the month which can be described 
as certainly and specifically curative of the diseases of the 
skin. The number of medicinal agents employed with this end 
in view is incredibly large, by far the greater part beiii^ obtained 
from the vegetable kingdom. With the few exceptions given 
below, not one of these is known to exercise the slightest reme- 
dial action upon the surface of the body, though it can scarcely 
be doubted that the list will be enlarged as experiments in this 
direction multiply. Other so called remedies are, for the most 
part, utterly without value of any sort; but will continue to be 
vaunted as specific, so long as credulity on the one hand, and 
avarice on the other, move the masses of mankind. 

The remedial agents employed internally and recognized as 
possessed of some value in diseases of the skin, are arsenic, mer- 
cury, iodine, cod-liver oil, quinine, ergot, and carbolic acid. Of 
them all, it may be said that while each possesses a wide range 
of usefulness, no one of them in any case can be certainly trusted 
to produce a given effect; and each in many cases is either posi- 
tively prejudicial or without, efficacy of any kind. 

Arsenic, which properly stands at the head of this significantly 
short list, is known to exert its effects almost exclusively upon 
the epithelia of the skin, and upon these, so far as therapeutic 
effects are concerned, only when they are in indolent conditions, 
subacute and chronic pathological states. It is known to exert 
an unfavorable influence upon the epidermis when the latter 
participates in a condition of active inflammation. Operating 
in this limited class of cases favorably, it also operates slowly, 
requiring months for the production of its curative effects. Its 
administration is at all times attended with the hazard of pro- 
ducing toxic effects, which, however, when the result of the ex- 
hibition of the drug in medicinal doses, are usually limited to a 
mild exanthem upon the skin, moderate coryza and some redness 
from congestion of the vessels in the eyes and eyelids. 

It is used chiefly in psoriasis, acne, squamous eczema, pem- 
phigus, and lichen ruber; its dosage in cases of children being 
relatively large. It should be invariably administered only after 
eating, and a minimum dose be first employed in order to test 
the susceptibility of the patient to its action. It should be re- 
membered that the toxic effect of this, as also of several of the 
other drugs mentioned below, is often speedily noticed after the 
first exhibition of a relatively small dose. Toleration once 
established, the dosage ma} r be cautiously increased. 

The forms in which it is usually administered are the prepa- 
rations of arsenious acid, such as the liquor potassii arsenitis 



GENERAL THERAPEUTICS. 71 

(Fowler's solution); the liquor arseuiei et hydrargyri iodidi 
(Donovan's solution); the liquor arsenici chloridi, and the 
Asiatic pill. Duhring's modification of this pill is obtained by 
making two grains (.13) of arsenious acid, and thirty -two grains 
(2.2) each of black pepper and liquorice powder, into thirty-two 
pills by the aid of a sufficient quantity of mucilage. Arsenic is 
also at times advantageously combined with other indicated 
medicinal substances, such as iron and the iodide of potassium. 
As already intimated, an unprejudiced view of its action, even 
in cases properly selected for its administration, will justify the 
statement that it is a remedy of uncertain effect, and, in that 
proportion, disappointing. 

The value of Mercury in the sypbilodermata is incontestable, 
and its injudicious employment in many cases springs from that 
precise fact. The vulgar prejudice that many disorders of the 
skin, really not syphilitic, are obscure manifestations of lues in 
a preceding generation, and amenable to mercurial treatment, 
is a striking illustration of the necessity of accurate diagnosis 
in cutaneous diseases. Few non-syphilitic affections are bene- 
fited by continuous courses of mercury, though the value of 
the metal as an alterative in this small proportion of cases must 
be admitted. The corrosive sublimate is well nigh superseded, 
in consequence of its irritative effects, by the compounds of the 
metal with iodine. The gray powder is useful chiefly in case 
of infants and children, though its not infrequent development 
of the corrosive chloride has largely limited its favor with 
Americans. Calomel and the mercurial pill should be employed 
onl}^ for transient effects, as, when administered for long periods, 
they are much more apt to produce ptyalism than the other 
preparations mentioned. 

Iodine and its compounds are also chiefly used by the derma- 
tologist in syphilitic disorders of the skin, but they possess a 
wider range of value than the mercurials in the treatment of 
other cutaneous affections. Here too the abuse of the drug fur- 
nishes the clinicien with a long list of cutaneous disorders either 
originated or aggravated by its employment. As in the use of 
arsenic, toleration should be established before large doses are 
exhibited. The compounds chiefly used are the iodides of potas- 
sium, sodium, lithium, and ammonium, and, quite recently, 
iodoform. It has been administered for the relief of the scroful- 
dermata, the two varieties of lupus, keloid, and the syphilitic 
affections of the skin. As to the latter, it may be added, that 
in the earlier skin symptoms of lues, it is often a source of 
positive injury. 

Cod-liver Oil is a remedy of special value in diseases of the 
skin, and was for that reason held in high favor by the dis- 



VI GENERAL THERAPEUTICS. 

tinguished EJebra, though its action is almost exclusively that of 
a nutrient of the general system. It is employed chiefly for its 
roborant effects, and these are similar to those of the digestible 

aliments. Its special value in the treatment of infants and 
children affected with cutaneous disease cannot he questioned. 
It is. however, of great use also in maturer years, and is ad- 
vantageously exhibited in eczema, lupus, scrofula, syphilis, 
morphoea, scleroderma, and in all the disorders of the integu- 
ment accompanied by wasting. 

Quinine, administered both as a tonic and anti-periodic, is 
largely employed in cutaneous medicine for its generally recog- 
nized systemic effects. It produces, in certain susceptible 
individuals, a peculiar smoothness and softness of the skin, 
which usually disappear when the drug is suspended. Like 
arsenic and iodine, it is occasionally the cause of a generalized 
exanthem, and is capable of producing other toxic effects, 
such as failure of the heart's action, dizziness, and tinnitus 
aurium, symptoms recognized under the designation of cinchon- 
isra. It will of course exhib t its happiest effects in malarial 
affections with coincidence of cutaneous symptoms, and in the 
forms of disease of the skin associated with a neurosis. 

Ergot, whether hy exerting an effect upon the muscle bundles 
or vessels of the derma, or the uterus of the female, or yet by 
its influence upon the general economy, is thought to possess 
some value in the treatment of several cutaneous diseases occur- 
ring in both sexes. Such are acne, purpura, and a tew other 
disorders. 

Tar, Carbolic Acid, and Phosphorus are remedies which have 
been employed internally with appreciable effect in certain 
cutaneous disorders, but the action of each is uncertain, and at 
times highly prejudicial. They have been used with advan- 
tage in some cases of lupus, eczema, psoriasis, and pruritus; but 
their value is exceedingly limited. The difficulty attending 
their internal administration has been to a great degree a bar 
to their general employment. The "perles" of phosphorus, and 
the elegant elixirs of the same drug, prepared by the Messrs. 
Fairchild and Wyeth & Bro., seem to have obviated this diffi- 
culty in the instance of at least one of these articles. 

Unpromising as is perforce this brief review of the in- 
fluences which internal medicaments are capable of exerting 
upon the skin, it must not be forgotten that, while the treat- 
ment of the patient and the treatment of the patient's skin are 
practically one, there is some distinction to be drawn between 
them. No one would claim that castor oil, for example, pos- 
sessed any efficacy in the fracture of a femur, yet such a cathar- 



GENERAL THERAPEUTICS. 73 

tic is frequently ordered by the surgeon, with the happiest effect 
upon the condition of his patient in a splint. Such precisely is 
the inestimable value of a properly conducted internal medica- 
tion in cases of cutaneous disease. 

The consideration of this point introduces us at once and 
properly to the broad field of general medicine. He is totally 
unfit to treat cutaneous diseases, who is not qualified by educa- 
tion and experience for the general practice of medicine. The 
internal treatment of the patient suffering from a disease of the 
skin, is that which is in each case indicated by his general 
condition. Thus the aperients, cathartics, diuretics, and occa- 
sionally even the anodynes, are demanded, and, when judiciously 
employed, accomplish beneficial results. Few practitioners can 
afford to dispense with the use of the preparations of iron, for 
example, in cases of anaemia. Even the patient affected with a 
parasitic disease may need one of the bitter tonics, and the 
youth with vegetations upon the glans may require first to be 
rid of his blennorrhagia. 

J^or will he who accomplishes the largest success neglect con- 
sideration of the diet, hygiene, and social surroundings of the 
patient. The chief value of the various mineral springs and 
health resorts of this country lies in the change of the manner 
of living which they invite and necessitate. Sunshine, pure 
air, recreation after the care and toil of business, change of 
climate, of foods and drinks, and even of cooks, often decide 
the question of speedy recovery. Unfortunately, both in this 
country and abroad, many of the health resorts are peopled by 
unscrupulous charlatans, with a myopic tendency to attribute 
all the benefits to be derived from these sources to the medicinal 
virtues of this or that particular spring, aided always by treat- 
ment according to their own Very peculiar methods. Many 
patients affected with disease of the skin are thus made worse 
by a temporary residence at noted health resorts, and therefore 
it is often the case that a visit to the seashore, the mountains, 
or any healthful place in the country will be conducive to far 
greater practical results. 

In the external treatment of diseases of the skin, the indica- 
tions are, to hasten repair when this is possible; to alleviate dis- 
tress, if palliatives only are admissible; to absolutely destroy or 
excise the diseased tissue, when this is justifiable. The follow- 
ing are the principal substances employed as external applica- 
tions: — 

Water, either pure or medicated by holding other substances 
in solution or mechanical suspension, is applied either in baths 
or lotions. Baths, local or general, may be employed for days 
continuously, or but for a few moments at a time. They are 
given with water of varying temperature, cold, warm, or hot. 
Cold baths of short duration are generally followed by a sharp 



74 GENERAL THERAPEUTICS. 

reaction, the skin hemming congested after the normal tempera- 
ture of the Burface is regained. Tims it is that cold sponging 
of the inflamed skin is usually grateful so long as it is contin- 
ued; and is succeed, m1 afterwards by sin aggravation of the 
symptoms which it was intended to relieve. Continued appli- 
cations of cold water are not open to this objection. Hot baths 
are followed by a more or less enduring relaxation of the integ- 
ument, while those given with tepid water are chiefly macera- 
tive of the surface. It should be remembered that the applica- 
tion of water to the broken surface of the skin, is liable to be 
followed by endosmosis, unless the specific gravity of the serum 
of the blood and that of the fluid of the bath or lotion are nearly 
the same. This imbibition of fluids by the broken skin is 
accompanied by slight swelling of the tissues and productive of 
disagreeable sensations. 

The most perfect of all methods by which water is applied to 
the surface of the body, is that which most resembles the water- 
hath in which the tender skin of the foetus is safely immersed 
for consecutive months. Here the bath is continuous; the tem- 
perature, that of the viscera of the living animal; the medica- 
tion, slight ; and the delicate skin of the unborn child, anointed 
with a fatty substance which actually interferes with the macer- 
ative action of the surrounding fluid so long as vitality is pre- 
served at the average standard. The comfort and therapeutic 
value of a bath prepared and administered in conformity with 
this rule, can scarcely be overestimated. Were it not for the 
difficult ies with which it is attended, so far as relates to many 
portions of the surface of the body, it would be possible with 
this single therapeutic measure to rob the exudative affections 
of the skin of a great part of their formidable features. 

Water for external application, is medicated by the addition 
of a large number of substances, such as marine salt, sodic and 
potassic salts, alum, tannin, the mineral acids, mucilages, gela- 
tin, bran, and, especially in the Southern States of this country, 
the orange leaf. 

When employed as a lotion, water is made to produce a seda- 
tive effect by the addition of opium, belladonna, glycerine, car- 
bolic acid, hydrocyanic acid, zinc, bismuth, mercury, lead, and 
the alkaline bicarbonates with the sodic hiborate. It is rendered 
stimulating by the admixture of alcohol, most of the acids and 
alkalies in stronger solution than in the soothing or sedative 
lotions; and by a large number of substances which operate upon 
the surface either mechanically or chemically. It is also ren- 
dered astringent when tannin, lead, and similar medicaments are 
dissolved in it; and by its union in various degrees with soaps 
and alkalies a solvent effect is produced, either upon the cuticle 
itself or upon pathological or foreign products upon its surface. 

Water is employed also, both in the form of the douche and 
vapor bath. When evaporation is prevented, by covering the 



GENERAL THERAPEUTICS. 75 

wet surface of the body with an impermeable tissue, such as 
gutta-percha or rubber cloth, still further macerative effect is 
produced. The sweat alone is in the same way converted into 
a macerating; agent. 

Lotions other than those containing water are often service- 
able. The fluid in such case may be alcoholic, ethereal, or ole- 
aginous, and medicated to any desired, effect. 

Fatty and Oily substances are applied to the skin either 
directly by pouring; or by friction; or by the mediation of 
compresses, bandages, etc., which are saturated or spread with 
the material to be applied. The oils may be used for either 
soothing or stimulating effects. To the former class belong cod- 
liver, lard, olive, almond, linseed, neatsf'oot, castor, and similar 
oils; to the latter, the oil of tar, of cade, of white birch, of the 
cashew nut, and of juniper. 

Fatty substances are also applied in the form of Ointments or 
Pomades. They are compounded with various medicinal sub- 
stances, according to the requirements of each case, such as the 
salts of mercury, zinc, copper, lead, and sulphur; carbolic, pyro- 
gallic, chrysophanic, and hyposulphurous acids; tar, camphor, 
iodoform, balsam of Peru, hydrate of chloral, the extracts of 
opium, belladonna, etc. 

Glycerine and the products of petroleum refinement, known 
as Vaseline and Cosmoline, though not true fats, are increas- 
ingly employed for similar purposes, and have met with high 
favor in this country and abroad. 

Plasters are employed when it is desired to exert a more or 
less continuous effect upon the skin. Among those chiefly' used 
may be named mercurial, soap, and lead plasters. 

Powders are mechanically dusted over the surface of the skin 
for the purpose of protecting it, and occasionally in order also 
to produce an astringent or antipruritic effect. In order to be 
serviceable, they should generally be rendered impalpable by 
sifting them carefully through a fine silk bolting cloth. They 
are composed of starch, lycopodium, bismuth, camphor, tannin, 
oxide of zinc, salicylic acid, and similar substances. The arti- 
cles sold by the grocers as " Oswego Gloss Starch" and "Corn 
Starch Farina," are usually much more finely bolted than the 
dusting powders prepared by the chemists extemporaneously. 
As absorbent powders, the starchy substances are open to the 
objection of forming little pasty rolls or "cakes" when wet with 
serum or sweat. Lycopodium, which is seen under the micro- 
scope to consist of irregularly globular pollen sporules, never 
behaves in this fashion; and is, for that reason, deservedly pop- 
ular. 



lb GENERAL THERAPEUTICS. 

Son]- arc of great value when applied to the skin. The hard, 
or Boda, soaps are employed chiefly for the purposes of ablution. 
The Boft, or potash, Boap lias a wider therapeutic range. In 
consequence of the small excess of caustic potash which it con- 
tains it not only serves to cleanse the skin of any accumulations 
upon its Burface, native or foreign, but also to exert a mild, 
destructive effect upon the horny layer of the epidermis. Di- 
ed with rectified spirits of wine in the proportion of two 
parts of the soap to one of the alcohol, it forms the well-known 
'•spiritus sapouis kalinus" of Ilehra, a preparation which the 
modern dermatologist employs constantly with admirable results. 

Medicated soaps, containing carbolic acid, glycerine, tar, sul- 
phur, and various oils, are sold in the shops; but contain so 
small a portion of the individual medicament from which each 
is named, that they are practically worthless except for pur- 
poses of ablution. The author has had such [prepared under cold 
pressure, so as to contain medicinal substances in therapeutic 
proportions; but, after experimentation, lias concluded that 
other forms of administration are preferable. 

Many agents are employed upon the surface of the integument to 
produce in various degrees a caustic or destructive effort. Among 
these maybe named the thermocautery (Paquelin knife), gal- 
vano-caustic apparatus, the mineral acids and alkalies, ethylate 
of sodium, arsenic, chloride of ziuc, several mercurial com- 
pounds, acid nitrate of mercury, bichloride of mercury, chloride 
of antimony, sulphate of copper, and nitrate of silver. Several 
of these substances in weak solution are employed as milder 
agents for the production of irritative, or even various inflam- 
matory effects. To the latter class should be added iodine in 
tincture, chloroform, tartar emetic, castor oil and cantharides. 

These destructive effects are of advantage in the treatment of 
disorders of the integument due to parasites, either animal or 
vegetable. Of those employed for this purpose, and not men- 
tioned above, may be named petroleum and staphysagria, for the 
destruction of lice ; sulphur, styrax, and balsam of Peru, for the 
destruction of acari; sulphur and its compounds, and a number 
of derivates from tar, for the destruction of vegetable parasites. 

A variety of Surgical and other Appliances are found useful 
as adjuvants in the treatment of skin diseases. They may be 
employed to support, protect, or compress the surface, or merely 
to aid in the retention of dressings or external medicaments. 
Thus tlie ordinary roller bandage is applicable to many portions 
of the body; the suspender, or suspensory bag, over tlie scro- 
tum; elastic or inelastic stockings to the feet and legs; kid, 
rubber, and thread gloves to the feet and fingers; and various 
skull-caps, face-masks, and mittens are employed in the case of 
infants and children to protect affected surfaces from the dangers 
of scratching. 



CLASSIFICATION. 77 

The instruments employed upon the skin for ordinary opera- 
tive, exploratory, or dressing purposes, need not be numerous. 
The author's case contains the following useful articles: — 

One set of variously-sized dermal curettes. These little sharp- 
edged spoons are for erasion of the surface, and should con- 
sequently have in each a fenestrum large enough to permit the 
escape of all collected substances from the floor of the spoon. 

One pair of epilating forceps with easy spring, and smooth 
blades meeting in perfect apposition. 

One pair of tine dressing forceps. 

One pair of fine curved scissors. 

Several comedone extractors. These should not be provided 
with piston and needle, but have a superior opening for escape 
of sebaceous accumulations. 

One half-inch lens for examining the surface of the skin. 

One set of needles in ivory handle. 

One set or* " gynecological" needles and needle-holder, for 
entering sebaceous and hair follicles, attacking small warts, etc. 

Two fine scalpels. 

One exploring needle. 

One set of fine probes. 



VII. 
CLASSIFICATION. 



TnE numerous attempts which have been made to classify 
diseases of the skin according to their nature and relations, have 
been a response to the generally recognized demand for a sys- 
tematic arrangement of all scientific facts. As regards derma- 
tology, not only have these attempts been numerous and based 
upon different principles, but the results which they have ac- 
complished have been in the highest degree divergent. No 
single classification yet devised has hitherto secured general ac- 
ceptance. While it is certain that no one of them has been per- 
fect and that each has exhibited defects, it is equally true that 
of the larger number each has possessed some merit of its own. 
It is probable that no perfectly satisfactory classification of cu- 
taneous diseases can be generally accepted till the knowledge of 
diseases of the skin has been greatly enlarged. 

The most satisfactory of alt the systems thus far proposed is 
that of Hebra. By it cutaneous disorders are arranged in the 
following nine classes : — 



CLASSIFICATION. 

CLASS I. Disorders of Secretion. 



( Jlass 


II. 


Eypersemias. 


Class 


III. 


Exudations. 


Class 


IV. 


1 hemorrhages. 


Class 


V. 


Hypertrophies. 


Class 


VI. 


Atrophies. 


Class 


VII. 


New Growths. 


Class VIII. 


Neuroses. 


Class 


IX. 


Parasites. 



This classification is essentially observed in the arrangement 
which is appended, the difference between the two resting upon 
the fact that in the latter the diseases are grouped primarily 
according to the regions involved, and secondarily upon the 
anatomico-pathological peculiarities which constitute the basis 
of Hebra's system. 

The chief reason for this change is the need of associating in 
a single group the disorders which naturally, that is clinically, 
either concur or undergo transformation the one into the other. 
Thus, for example, I have long found it a source of inconveni- 
ence and confusion to separate seborrhcea, which is named in the 
first of Hebra's classes, from acne, which, being essentially exu- 
dative, is described among the disorders included in the third of 
these classes. In the same way a somewhat unnatural divorce 
has been procured between the several disorders of the pilary 
system, some of which, as sycosis non parasitica, are found in 
one class, while the hypertrophies and atrophies of the hairs are 
found disassociated and each in a separate group. 

The subjoined system of classification, while it does not do 
violence to the arrangement of Hebra, is one therefore which I 
believe to be practically useful: — 

A CLINICAL CLASSIFICATION OF THE DISEASES OF THE SKIN. 

Class I. Involving predominantly Furunculus. 

the component parts of the epi- Anthrax, 

dermis and derma, and incident- Psoriasis 
ally the appendages of the skin. 



llvri II.EMIC. 

Erythema simplex. 
Erythema intertrigo. 
Exudative. 
Erythema multiforme 

Papillosum. 

Bullosum. 

Nodosum. 
Urticaria. 
Eczema. 
Dermatitis. 



Pemphigus vulgaris. 
Dermatitis exfoliativa 
ralis. 

Pityriasis rubra. 

Pemphigus foliaceus. 
Impetigo herpetiformis. 
Lichen ruber. 
Prurigo. 
Zoonoses. 

Pustula maligna. 

Equinia. 
Hypertrophic. 



Molluscum epitheliale. 

,I, ; I I 1"' S - • Keratoses. 



Herpes iris 
Herpes zoster. 
Impetigo. 

Impetigo contagiosa 
Ecthyma. 



Of the epidermis chiefly. 
Callositas. 
Clayus. 
Cornu. 



CLASSIFICATIOiN'. 



b. Of the derma chiefly. 
Verucca. 
Ichthyosis. 
Elephantiasis. 
Dermatolysis. 
Sclerema neonatorum. 
Scleroderma. 
Morphcea. 

4. Atrophic. 

Atrophia cutis. 

Atrophia senilis. 

Strise et maculae atrophica?. 

5. Neoplastic. 

Lupus erythematosus. 

Lupus vulgaris. 

Keloid. 

Molluscum fibrosum. 

Xanthoma. 

Adenoma. 
PJiinoscleroma. 

Class II. Of the sebaceous glands 
and periglandular tissues. 

1. Anomalies op secretion. 

Seborrhcea. 

Oleosa. 

Sicca. 
Comedo. 
Cyst. 

Milium. 

Wen. 
Asteatosis. 

2. Exudative. 

Acne. 

Acne rosacea. 

Class III. Of the sweat glands and 
periglandular tissues. 

1. Anomalies op secretion. 

Hyperidrosis. 

Bromidrosis. 

Anidrosis. 

Chromidrosis. " 

Secretion of otherwise altered 

sweat. 
Sudamina. 

2. Exudative. 

Miliaria. 
Miliary fever. 
Dysidrosis. 

Class IV. Of the hairs, hair-fol- 
licles, and perifollicular tissues. 

1. Atrophic. 

Alopecia. 
Alopecia areata. 
Alopecia furfuracea. 
Atrophia pilorum propria. 
Canities. 

2. Exudative. 

Sycosis non-parasitica. 
Dermatitis papillaris capil- 
litii. 

3. Hypertrophic. 



Keratosis pilaris. 
Hypertrophy of the hairs. 

Class V. Of the nails. 

Hypertrophy. 
Atrophy. 

Class VI. Of the blood and lymph- 
vessels and perivascular tissues. 

1. HEMORRHAGIC. 

Purpura. 

2. Neoplastic. 

Angioma. 

Nsevus vasculosus. 

Telangiectasis. 

Angioma cavernosum. 
Lymphangioma cutis. 

Class VII. Of the nerves. 

1. Anomalies of sensation. 

Pruritus. 

Pruritus hiemalis. 

Hyperesthesia. 

Anaesthesia. 

Dermataltna. 
2. Neoplastic. 

Neuroma. 

Class VIII. Of the pigment. 

1. Hypertrophic. 

Lentigo. 

Chloasma. 

Naevus pigmentosus. 

2. Atrophic. 

Albinismus. 

Vitiligo. 

Leucoderma. 

Class IX. Of the skin with involve- 
ment of other organs. 

1. Exudative. 

The exanthematous fevers. 
Erysipelas. 

2. Neoplastic. 

Scrofuloderma. 

Lichen scrofulosorum. 
Lepra. 

Syphiloderma. 
Carcinoma. 

Epithelioma. 
Myeloma (sarcoma). 

Inflammatory fungoid neo- 
plasm. 

Class X. Of the skin and its appen- 
dages, all parasitic. 
1. Produced ry vegetable 
parasites. 
Tinea favosa. 
Tinea trichophytina. 
T. circinata. 
T. tonsurans. 
T. sycosis. 
Tinea versicolor. 



DISEASES OF THE SKIN. 



Class T. — INVOLVING PREDOMINANTLY THE COMPONENT 
PARTS OP THE EPIDERMIS AND DERMA, AND INCIDENT- 
ALLY THE APPENDAGES OP THE SKIN. 



1. Hypsraemic. 



The hypersemic disorders of the integument are so termed 
because they are chiefly characterized by an excess in the supply 
of blood to the part affected. This increased vascularity, lasting 
for a longer or shorter period of time, is, as is well known, the 
first and necessary stage of every inflammatory process. If every 
condition of hyperemia were succeeded by the exudation charac- 
teristic of inflammation, it would be manifestly improper to con- 
sider its phenomena as separate from that process. Such, how- 
ever, is not the case. A large list of disorders are those in 
which hyperemia is not succeeded by exudation, and thus arises 
a clinical demand for their separate consideration. 

As hyperemia touches upon one side the pathological process 
of inflammation, so, upon the other, it extends to the physiologi- 
cal changes in the vascular currents constantly manifested in the 
healthy skin and illustrated in the phenomenon of blushing. 
Between these extremes, with ill-defined limits on either hand, 
occur the purely congestive affections of the integument. 

Hyperemie disorders are usually first classified into those 
which are active, characterized by direct increase of blood-sup- 
ply, and those which are passive, characterized by blood-stasis 
from interference with the return of the circulating fluid. Clini- 
cally, the distinction thus established is of minor importance. 
Active and passive hyperemias differ from each other chiefly in 
the intensity of the induced coloration, the elevation of the tem- 
perature accompanying the process, and the subjective sensations 
they occasiou. 

A more important distinction is that between idiopathic and 
symptomatic hyperemias. The former are properly disorders of 
the skin, and result from direct causes operating externally upon 
its surface. The latter are surface congestions induced by influ- 
ences operating within the body, with the effect of producing 
changes in the circulatory system. An idiopathic active hyper- 
emia of the skin can be induced by the action of mustard applied 



v i DISEASES OF THE SKI X. 

to its surface; ;>n idiopathic passive hypersemia, by encircling a 
finger with a closely-fitting rubber Btrap; a symptomatic active 

hypersemia is seen in the cheek of a child with frankly developed 
fever; and a symptomatic passive hypersemia, in the finger- nail 
of a patient suffering from a severe attack of asthma. 

Cutaneous hypersemias are generally distinguished by in- 
creased color, varying from a delicate rosy tint to a deep purple, 
occurring in points, patches, large areas, or in singular striatums 
of the surface. The colored portions rarehy project to an appre- 
ciable extent above the general level of the unaffected skin. 
They are never accompanied by infiltration of the tissues, and 
hence when a portion of the hypersemic integument is pinched 
up between the finger and thumb, it is at once felt to be un- 
changed in pliability and thickness. The temperature of the 
part may be normal, slightly increased, or, rarely, diminished. 
The subjective sensations induced are usually a trifling itching 
or burning, and may be wholly wanting. 

Pathologically, the hypersemias may be described as occa- 
sioned exclusively by an increased afflux of blood to the supe- 
rior pars vascularis of the eorium. The differences in the shade, 
contour, and extent of the coloration are due to the preponder- 
ance of arterial or venous blood in the vascular elements, its 
condition of stasis or rapid transmission, and the area of altered 
vascular supply. The vaso-rnotor nerves, in the production of 
this alteration, play an important part. 

Erythema Simplex. 

Deriv., Gr. ifu0«,u.*, redness. 

Erythema simplex is a coloration of the skin in various shades of redness, tem- 
porarily disappearing under pressure, the lesions differing in size and shape 
according to the extent and degree of the hyperemia by which they are in- 
duced. 

Idiopathic Erythema. 

Erythema Traumaticum. — Here the redness is the result of 
friction, rubbing, pressure, scratcbing, and similar external con- 
tacts. It is observed, for example, in the part pressed by the 
pad of a truss; in the colored circle left about the leg where a 
tight garter has been worn; on the sides of the nose where pres- 
sure is exerted by a newly-applied pair of eye-glasses. These 
traumatic hypersemias are readily converted into exudative affec- 
tions, if the traumatism be long continued. Intermittent pres- 
sure upon the skin permits restoration of the vascular equilib- 
rium, and the skin responds to the demand made upon it by 
increasing in thickness; continued pressure, on the contrary, 
admits of no such restoration; and the integument finally be- 
comes thinner and yields before the agent inflicting the injury. 
Inflammation resulting in ulceration may finally supervene. 



ERYTHEMA SIMPLEX. 85 

Erythema Calortcum. — Solar heat in excess and extremes of 
cold; very hot and very cold water; and other heat-conducting 
substances, are also sufficient to induce transitory redness of the 
surface. In the erythemata induced b} 7 solar heat especially, 
there is frequently an increase in the pigmentation of the sur- 
face, as in the production of freckles and "tan" in persons whose 
skins are reddened by the sun. The darker, brownish and choco- 
late-colored stains of the hands and face are thus induced. 

Erythema Venenattjm. — A number of chemical substances, 
d} 7 es, and vegetable poisons are also capable of producing tran- 
sient hyperemia of the skin. Among these may be mentioned 
cantharicles, capsicum, mustard, aniline, chloroform, ether, ar- 
nica, and several of the essential oils. 

Symptomatic Erythema. 

A long list of phj'siological and pathological causes operating 
upon the system at large are capable of inducing active symp- 
tomatic hyperemia of the skin. This may be generally diffused, 
or occur in surface mottlings and markings of various sizes and 
shapes. Thus the skin of the face may be intensely reddened 
in a paroxysm of rage; and that of the limbs of a teething child 
covered with rosy maculations in consequence of the reflection 
to the surface, through the medium of the nervous system, of 
the irritation induced by a tooth. In consequence of the rosy 
tint assumed by several of these rashes, they have long been 
termed "roseola," a name which today is held to describe a 
symptom rather than a disease. The word "roseola" is still 
associated in the minds of many with the earliest syphiloderm; 
but that eruption is now designated by the best authors as the 
erythematous or macular syphilide. 

Several of the severer constitutional maladies betray their 
morbid influence upon the central nervous system by a speedy 
efflorescence of this character. A lurid erythema of the axillary 
or inguinal region may precede by several days the eruption of 
confluent variola. Cholera, cerebro-spinal meningitis, enteric 
and other fevers are thus at times accompanied, preceded, or 
followed by rashes. A study of these is of the utmost import- 
ance to the diagnostician. Children who are really susceptible 
to the disease are often supposed to possess an immunity from 
scarlatina, as the symptomatic erythema they previously dis- 
played was misconstrued. 

JDiagnosis. — If an erythema of the surface exists and is mani- 
festly unattended by exudative symptoms, the recognition of 
the condition of the skin is not difficult. A more serious prob- 
lem, however, concerns the significance of this symptom when 
it occurs in connection with grave constitutional maladies. A 
high temperature, severe lumbar pain, great gastric or intestinal 



86 DISEASES OF THE SKIN. 

irritability, coryza, and injection of the ocular conjunctiva), are 
symptoms which should always put the practitioner on his guard 
in pronouncing upon the nature of an erythema. 

On the other hand, patients in a state of alarm, frequently 
seek relief for an idiopathic erythema, of the nature of which 
they are ignorant. Here the locality, contour, and general ap- 
pearance of the eruption, taken in connection with the history 
of the case, will usually suffice to establish a diagnosis. 

Treatment. — The symptomatic erythemata are usually of such 
trifling significance in comparison with the constitutional dis- 
order by which they are occasioned, that the removal or man- 
agement of the latter becomes of the higher importance. The 
idiopathic erythemata are usually relieved at once by the suspen- 
sion of the cause. Occasionally cold water, weak spirit lotions, 
dilute solutions of carbolic acid, or one of the dusting powders 
may he required. The ordinary rubher, adhesive, or lead plas- 
ter, may he applied to erythematous surfaces where the friction 
must necessarily be continued (surgical appliances, orthopaedic 
apparatus, etc.), and in those produced by constant pressure 
(nates and sacrum in low fevers or surgical confinement), it 
should never be forgotten that the hyperaemic is also a weak- 
ened skin. Here stimulating applications may be needed, alco- 
holic, camphorated, etc., with a view to the restoration of the 
tone of the weakened capillaries. 



Erythema Intertrigo. 

Derid. Lat. inter, between ; terere, to rub. 

Erythema intertrigo is an hypera?mic condition of those cutaneous and muco- 
cutaneous surfaces which are in constant apposition, and between which 
there is an hypersecretion or retention of sweat. 

Symptomatology. — The erythema which is limited to portions 
of the integument which lie in contact with each other, is sub- 
ject to certain modifications. The sites of such contacts in the 
human body are the axillas, the groins, the cleft between the 
nates, the inter-mammary and infra-mammary spaces in the 
female, the superior and inner faces of the thighs, the scroto- 
femoral and the labio-femoral clefts in the sexes respectively, 
the flexures of the joints, and in especially fat individuals, all 
those parts where the integument is thrown into fleshy folds, 
as about the neck of infants, and even over the crest of the ilia 
in fat women. In these localities the disorder, beginning as an 
erythema traumaticum, proceeds b} T its irritative effects to 
stimulate the secretion of sweat, which is freely poured out 
between the adjacent folds of the skin, and may there be tem- 
porarily imprisoned. The surface, heated and reddened, is also 
somewhat macerated by the effused perspiration; and the latter, 
when chemically altered, as it is frequently under these circum- 



ERYTHEMA INTERTRIGO. 87 

stances, adds still further to the original disorder. The ground 
is thus well prepared for an exudative process, hut the disorder 
may be limited to mere hypersemia with hyperidrosis of sweat, 
and disappear before the supervention of actual inflammation. 

The sensations produced are those of heat and tenderness. 
"When the parts in contact are separated, the surfaces are seen to 
be reddened and chafed. Here and there very superficial abra- 
sions of the macerated epidermis become evident. One such is 
always especially significant. It is the linear and superficial 
excoriation which marks the line of deepest contact of the two 
apposed surfaces of the skin at the bottom of the angle formed 
by the two. An offensive odor usually proceeds from the part 
in consequence of the fluid secreted. Fox, of London, has called 
attention to the fact that the secretions of an intertrigo stain, 
but do not stiffen the linen of the patient, and thus differ from 
the serous fluid poured out in an exudative dermatitis. 

Etiology. — The disease is chiefly induced by heat, friction, and 
moisture, — these causes occasionally cooperating. The heat 
may be merely that of the natural temperature of the body, or 
it may be increased by that due to season and climate. The 
friction also may be merely that originating between the sur- 
faces in apposition, or may be increased by clothing or other 
articles worn next the skin. The moisture which produces 
maceration of the epidermis is that originating in the perspi- 
ratory follicles, their secretion being doubtless stimulated by the 
heat and friction. The interchange of operation of these three 
factors is, lastly, shown by the fact that the friction, if severe, 
is capable of increasing the temperature of the part to which it 
is applied. 

As aggravating causes may be named other physiological secre- 
tions and excretions, retained in contact with the surfaces affected 
with an intertrigo. Thus the faaces of the infant left in contact 
with its nates upon the napkin ; the urine of the old man with 
paralysis of the bladder, or with "overflow" from prostatic dis- 
ease; the milk of the nursing woman dribbling over the breast 
to the infra-mammary region; retained lochial, menstrual, and 
similar discharges, are all efficient in this regard, and particularly 
apt to induce that form of dermatitis to which the intertrigo 
then plays a subordinate part. Occurring in fleshy persons, 
these conditions find their most fertile field. 

Diagnosis. — The recognition of a simple erythema intertrigo 
is a matter of no difficulty, if regard be had to the exciting and 
aggravating causes enumerated above, and to the special locali- 
ties where such hyperemia generally originates. If an eczema 
or dermatitis supervene, the fact will appear from increased sub- 
jective sensation (usually a severe itching), from an infiltration 
of the affected integument, and from the appearance of those 
lesions and discharges which are significant of these forms of 
inflammation of the skin. 



88 DISEASES OF THE SKIX. 

The special sites of preference of an intertrigo are tliose also 
of the disease named by Eebra "eczema marginatum," or ring- 
worm as it occurs upon the parts of the thighs covered by the 
" reinforced" patch in the trowsers of the cavalryman. The 
disease is properly named, tinea circinata cruris, though it is 
found also about the axilla?, buttocks, and groins of both sexes. 
Here the disorder is, however, of the exudative- typo, and, more- 
over, is distinguished by a characteristic "festooning" of the 
elevated border marking the advancing limit of the disease. 
The microscope, by revealing the existence of a fungus, will 
of course put an end to any doubt. In intertrigo the most 
marked evidence of disease is to be distinguished in the deeper 
parts of the cleft between the two adjacent skin surfaces, while 
in tinea circinata cruris the growth of the parasite is most active 
at the advancing border of the patch, which is, moreover, per- 
ceptibly elevated above the sound skin. 

Treatment — Erythema intertrigo is an exceedingly common 
affection of the skin, and occasionally proves of great annoyance 
to those suffering from it. The skill of the young practitioner 
is often tested early in his professional career by his management 
of just such cases; and not a little may depend upon the success 
witli which he may be rewarded. 

The affected surfaces should be gently cleansed by ablution 
with soap and warm water, and the offensive odor of the secre- 
tions remedied by the addition to the water of a weak solution 
of carbolic acid, or the dilute liquor sodas chlorinate. The parts 
are then to be carefully dried with a fresh ly-laundried towel or 
soft handkerchief, and afterward one of the dusting powders 
very thoroughly applied. To be of service these must be quite 
impalpable, and, if compounded by the druggist, be sifted through 
a miller's fine silk bolting-cloth. The articles chiefly used for 
this purpose are: Bismuth, starch, zinc oxide, French chalk, 
lycopodium, and, when an anti-pruritic effect is designed, cam- 
phor. Combinations of several of these are at times effective. 
The formula of M'Call Anderson is highly esteemed, and con- 
sists of: — 

R. Zinci oxid. pulv. §ss ; 16 

Campbone pulv. ."jss ; 6 

Amyli pulv. §j ; 32 M. 

Sig. Anderson's dusting powder. 

The following is the formula for a dusting powder recom- 
mended by Klamann. 1 

R. Talc, venet. pulv. ^v ; 20 

Acid, salicyl. gr. iij ; 2 

Magnea. ust. subtil, pulv. 3jss; 5 31. 

Sig. Dusting powder. 

1 Hebam. Kalend., Obstet. Gazet., March, 1882. 



ERYTHEMA INTERTRIGO. 89 

The "Oswego gloss starch" and the "corn starch farina" sold 
by most of the grocers in this country, are finely bolted, and 
answer well alone, or in combination with some of the other 
articles named. The chief objection to the starch-containing 
powders is their tendency to form little "cakes" or rolls when 
wetted with the sweat, these masses further irritating the 
tender surface of the skin. Such an objection does not apply to 
lycopodium, which not only under the microscope exhibits no 
salient angles, but on account of the oil it contains is not mis- 
cible with water. 1 

The affected surfaces of the skin must also be separated in 
order to prevent further friction. A thin strip of lint, or the 
antiseptic cotton now in the market, may be used for this pur- 
pose; and must be pushed well up to the deeper portions of the 
cleft where the secretion chiefly forms. Occasionally it will be 
found useful to anoint this absorbent layer with cold cream or 
vaseline. Where an astringent effect is desired, the lycopodium 
or other dusting powder may be compounded with tannin, alum, 
or similar substances. The list of lotions may be also at times 
consulted with advantage. Thus, cologne water, weak spirit 
lotions, tannin and aromatic wine, or carbonate of magnesium, 
may each be serviceable. Lastly, the charron oil (equal parts of 
lime water and linseed oil), spread thickly upon linen, will pos- 
sibly give more relief than the other articles named; the chief 
objection to it being the consequent soiling of the patient's 
clothing. 

The best treatment is that which is accomplished with a gentle 
and yet efficient dressing of all the parts. The care and nicety 
requisite, may be appreciated when one considers that in some 
very fleshy women there are several square feet of surface which 
may be at one time affected with erythema intertrigo. 



2. Exudative. 

Under the title of exudations are classed all those affections 
of the skin, which on the one side are limited by the boundary 
lines of the hypergemise already described, and on the other are 
distinguished by the severest types of dermatitis. In the classi- 
fication here employed, only those exudations are now to be 
considered which affect the skin proper, and which, afrer involu- 
tion of the process is at an end, leave no persistent traces of their 
career in the integument. 

1 I have been in the habit of illustrating this fact to my classes at the college, 
by sprinkling a thin layer of lycopodium over the surface of the water held in 
a. goblet nearly filled. The finger may then be thrust quite to the bottom of 
the glass through the water, and, when removed, will be found to be as dry as 
when it entered. It has been so completely ensheathed by the lycopodium that 
not a drop of the fluid has come in contact with its surface. 



90 DISEASES OF THE SK IX. 

The diseases of this group will naturally differ according as 
the degree of exudation present justifies their assignment to <»ne 
or the other of the extremes named above. Thus, in erythema 
multiforme and urticaria, the exudative process is less distinct 
and exaggerated than in cither pustular eczema or bullous der- 
matitis. 

The presence of an exudation in the sense in which the term 
is here used, necessarily implies that the inflammation by which 
alone it can he produced, has either preceded or is actually pre- 
sent. The pathological processes implied by the term inflamma- 
tion of the skin, will he described fully in considering the nature 
of the most common disease in this category, viz., eczema. It 
is sufficient to note here, that the clinical signs of an exudative 
process in the integument are the occurrence of any lesions upon 
its Biirface which indicate that the hyperemia of its vessels has 
been succeeded by an exudation of serum, or any increase in the 
hulk of the skin in consequence of the multiplication of its pro- 
toplasmic elements. An integument which is the seat of an 
exudation is thus, clinically considered, either the field upon 
which are visible one or more of the elementary lesions of the 
skin other than macula?, or is with difficulty gathered up be- 
tween the thumb and finger in consequence of its augmented 
thickness and diminished suppleness. 

This group includes by far the larger number of all diseases 
of the skin of every kind ; and the necessity for its careful study 
is correspondingly imperative. 



Erythema Multiforme. 

Erythema multiforme is an exudative disease of the skin, in which appear flat 
or elevated lesions of an erythematous type in various forms, the exanthem 
being at times symptomatic of constitutional derangement. 

Symptomatology. — In this affection, which is usually of sym- 
metrical development, erythematous maculae, flattened papulae, 
and even large flat nodosities, very rarely vesicles, occur, usually 
upon portions of the extremities, the forearms, the legs, and the 
dorsum of the hands and feet. The eruption, which is much 
more generally recognized in clearly defined patches, usually 
commences with pin head to finger-nail sized macules of a dark- 
ish-red shade, losing their color under the pressure of the linger, 
which in the course of some hours exhibit tumefaction in vari- 
ous degrees, producing thus the papules, tubercles, and nodes 
already described. The disease may persist for but a few days, 
but in severer grades it lasts for several weeks. In the height 
of the exudative process, there is usually an efflux of the color- 
ing matter of the blood into the skin which is the site of the 
several lesions; and thus are produced the singular shades of 
reddish-black, purple and red, blue and red, yellow and orange, 



ERYTHEMA MULTIFORME. 91 

which are so characteristic of simple bruises of the extremities 
when the injury has been sufficient to cause extravasation of 
blood. The lesions occur in various shapes, sizes, and shades, 
and a number of names have been used to designate their seve- 
ral appearances, which require explanation though they are 
without any practical value. 

Erythema Annulare is characterized by central paling of 
color and peripheral extension of the erythematous patch, in the 
form of a ring. 

Erythema Figuratum occurs in gyrations formed by coales- 
cence of two or more annular circles. 

Erythema Iris is the result of successive new erythematous 
centric colorations, by which at times several differently shaded 
concentric rings are formed. 

Erythema Marginatum is that form in which a distinctly ele- 
vated and denned marginal band is left as the sequel of an ery- 
thematous patch. 

Erythema Nodosum is regarded by several authors as a distinct 
affection. In it the characteristic lesions are of the dimensions 
of semi-globular pea to fist-sized tumors, pale red to livid blue 
in color, tender upon pressure, exhibiting in their involution 
the variegations of hue already described. They occur at times, 
not only in the localities named above, but also upon the trunk 
and face. Though occasionally becoming so soft to the touch 
that fluctuation may seem to be present, they never terminate 
by suppuration. 

Erythema Papulatum (or Papulosum) and E. Tuberculatum 
(or Tuberculosum) are those forms in which occur respectively 
lesions of a papular or tubercular type. 

Erythema Urticatum is that form in which there is severe 
itching, and, as a result, scratching of the lesions with crusts of 
dark dried blood at the summit of each. This crust is sur- 
rounded by the light red or bluish-red, flattened or elevated 
patch characteristic of the disease. 

Erythema Yesiculosum and E. Bullosum are rare and excep- 
tional forms where the exudation is sufficient to raise the 
horny layer of the epidermis into larger or smaller serum-con- 
taining chambers. These may be, as regards the erythematous 
patch, of central or peripheral situation; and may crown the 
summit of papule or tubercle. The fluid is usually removed by 



02 DISEASES OF THE SKIN*. 

absorption, and is rarely set free by rupture of the vesicle or 

bleb. 

The name, multiforme, given to this disease by Hebra, is thus 
seen to be justified by the singular variety of lesions which it 
displays. 

The subjective symptoms, save in the urticarial form of the 
disease, are usually of a trifling character. The slight sense of 
heat and burning awakened by the lesions, is altogether out of 
proportion to the extent of development of the latter. 

The symptoms, however, indicative of a general disturbance 
of the system may be of a marked character. General malaise 
fever, inappetence, pharyngeal inflammation, chills, severe gastro- 
intestinal disorder, rheumatoid involvement of the articula- 
tions, and even organic changes in the heart (valves, endocar- 
dium and pericardium), lungs and kidneys (Kaposi), have all 
been noted as coincident or causative phenomena. In many of 
these caseB it is clear that the exanthem belongs to the list of 
symptomatic erythemata, and is of insignificance in comparison 
with the grave general condition. With these exceptions, how- 
ever, the prognosis is in general quite favorable, as the disease 
may terminate in a few days, and rarely exceeds a month in 
duration. 

Occasionally the mucous membranes are affected to a disagree- 
able or even painful extent. Thus a sudden tumefaction of the 
uvula may supervene upon the cutaneous s} T mptoms, even in 
cases sufficient to impede respiration ; or the lining membrane 
of the larynx be involved and the resulting aphonia in various 
degrees persist for two or three days. 

Etiology. — " We are in a state of complete ignorance as to the 
cause of these erythemata." — (Hebra.) We simply know that the 
affection is more common in the spring and fall of the year ; that 
it occurs in the young, or in the early periods of adult life; that 
the papular and tubercular forms are more common in the male, 
and the nodose forms in the female sex ; and that in many cases 
it occurs in those who are affected with rheumatism. There 
can be but little doubt that its etiology includes a list of varying 
and widely differing causes. I have seen severe manifestations 
of the disease in a young woman with extensive ulceration of 
the cervix uteri. Tilbury Fox noticed its frequency in young 
servants brought to town from the country. It is not rare in 
young female immigrants who have recently made a " steerage " 
passage to this country. 

Fathology. — Erythema multiforme is essentially an hyperemia 
of the integument which, under certain obscure influences, ad- 
vances more or less rapidly to the stage of a mild grade of in- 
flammation with consequent exudation. If, with Landois and 
Lewin, it be accepted that the process is the result of vaso-motor 
nerve influence, it cannot be determined whether these nerves 



ERYTHEMA MULTIFORME. 93 

are centrically or peripherally irritated. In the case of erythema 
nodosum, Hebra advances what he admits to be an hypothesis, 
in saying that the morbid process is essentially an inflammation 
of the lymphatic vessels. In some cases it is evident that there 
is extravasation of blood from the vessels into the skin of the 
affected parts. 

Diagnosis. — Erythema multiforme is always to be carefully 
distinguished from the traumatisms producing bruises, especially 
upon the lower extremities. This is a point which may have 
an interesting bearing upon certain medico-legal questions, es- 
pecially in the case of young children. The tendency of the 
disease here considered to symmetrical arrangement, upon the 
two sides of the body ; the occurrence of lesions evidently dating 
from several periods, where successive crops appear; and the 
absence of all history of external injury, will usually suffice to 
establish a diagnosis. Among the precocious affections of the 
subcutaneous connective tissue in syphilis, Mauriac has described 
a lesion resembling somewhat the symptoms of erythema nodo- 
sum ; but in such cases, and especially in women, mucous 
patches of the vulva, anus or mouth, with coincident adenopathy, 
would point to the real nature of the disease. 

Treatment. — As the disease under consideration progresses 
naturally to a favorable termination within the course of a few 
weeks, the duty of the physician is usually limited to the ques- 
tion of diagnosis merely. He should remember that the larger 
lesions seen in erythema nodosum never suppurate ; and thus 
be not tempted to open them with a lancet. Local treatment 
is rarely called for ; and in any case should be restricted to the 
application of hot or cold water, as found most grateful to the 
patient, with possibly the use of a weak lead lotion. Internally 
such medication should be employed as is indicated by the gen- 
eral condition of the patient. Iron, quinine, strychnia, and the 
dilute hydrochloric acid will be found beneficial in many cases. 
Constipation and indigestion are to be corrected by appropriate 
measures. When the disorder is evidently purely symptomatic, 
the internal treatment is to be directed to the general condition 
present. In rheumatic cases, the indications for such treatment 
are clear. When the erythema produces extensive oedema of 
the uvula, incisions may be requisite to prevent dyspnoea and 
dysphagia. 

Prognosis. — It will be gathered from what has preceded, that 
the prognosis is always favorable. The fatal cases reported 
are usually those where the result was due to grave constitu- 
tional conditions, and where the erythema multiforme was an 
insignificant feature of the malady. The disease may relapse in 
susceptible individuals at those periods of the year when it is 
most frequently observed. 



94 DISEASES OF THE SKIN*. 



Urticaria. 

Deriv. Lat. urtica, the nettle. 
Urticaria is an exudative affection of the skin in which appear ephemeral, 
whitish, or rosy tinted wheals surrounded by a reddish areola, giving rise to 
an intense pruritus. 

Symptomatology. — This disorder, popularly known as the "net- 
tle-rash" or the "hives," is characterized by the sudden devel- 
opment of wheals upon the surface, which frequently disappear 
with equal rapidity, leaving behind no traces of their existence 
Bave a slight and transitory hyperemia of the affected spot. 
The lesions may he as small as a coffee-bean, and are usually of 
this size ; but in certain rare instances " giant wheals " are seen, 
large tomato-sized projections or flat elevations of broad areas 
of the integument, covering the greater part of the belly or the 
buttock. In color, they are either rosy-red or whitish ; and are 
usually surrounded by an hypenemic areola. They may be iso- 
lated and few; or numerous and closely packed together; may 
even coalesce so that individual lesions are scarcely recognizable. 
They are usually firm and semi-solid to the touch. Rarely the 
horny layer of the skin is raised in fluid-containing lesions by 
the sudden effusion of serum beneath. In shape they are round- 
ish or ovalish ; but a variety of curious outlines may result from 
the irregularity of their development. Thus concentric circles, 
lines, bands, and even figures, are in this way produced. The 
finger-nail drawn across the unaffected portions of the skin, in a 
patient with urticaria, will often produce a linear wheal of ex- 
tent corresponding to the line of irritation. It is said that in 
this way the so-called "medium" with a sensitive skin exhibits 
written characters upon the surface of his body. 

The subjective sensations induced by these lesions are distress- 
ing in various degrees, according to the susceptibility of the indi- 
vidual. Every grade of pruritic, burning, tickling, crawling, 
pricking, and especially stinging sensations are thus engendered. 
The efforts of the patient, to secure relief by scratching^ not only 
serve to still further develop the eruption, but to irritate, tear, and 
otherwise wound those lesions already in full evolution. In this 
way the serous effusions are produced at the summits of the 
wheal ; and in this way, also, the lesions really transitory in 
their course may be changed to more persistent, deeply-colored, 
flat, lenticular papules. Where the skin is delicate and thin, as 
that of the lids and prepuce, considerable oedema may result. 

All parts of the body may become affected, and this irre- 
spective of age and sex, though children are particularly liable 
to the disease. There are few very young children with skins 
unwashed for an entire month, who will not exhibit urticarial 
symptoms, if there be an added irritation of the surface. 



URTICARIA. 95 

The lesions may be numerically few, or so numerous as to cover 
the entire surface of the body. Though more frequently acute 
in course, they may recur frequently from apparently insignifi- 
cant causes, or even become chronic. In man} 7 cases trivial, the 
disease may become so aggravated as to make the largest de- 
mands upon the skill of the physician. 

The rapidity of appearance and disappearance of the lesions 
visible upon the skin is a characteristic feature of the disease. 
In some instances but a few moments are required after the 
operation of an efficient cause, to develop a large number of 
closely packed wheals upon the skin. Even while these are 
under inspection, it can be noted that there is a change in indi- 
vidual lesions, some fading or completely disappearing, while 
others are newly developing. 

A number of names have been employed to designate the 
several external peculiarities of the lesions as they are pre- 
sented to the eye. Thus u. annularis occurs in rings ; u. figu- 
rata in gyrations from union of several lesions or patches of 
lesions; u. vesiculosa and u. bullosa, where there is a vesicular 
or bullous development at the summit of the lesion ; and u. 
papulosa (or lichen urticatus), where there is a combination of 
the features of the wheal and the papule, the lesions being 
usually rape seed to coffee bean in size, and covered with blood 
crusts where their apices have been torn in scratching; u. tube- 
rosa, where "giant" wheals occur, some attaining the size of a 
hen's egg; u. hemorrhagica (purpurata urticata), where the 
urticarial element, is developed in a lesion produced by cutaneous 
haemorrhage ; and u. evanida, or perstans, where there is re- 
spectively a rapid or slow process ot involution in the character- 
istic symptoms. 

Urticaria Pigmentosa. 

In this form of the disease, characteristic wheals are succeeded 
by peculiar pigmentations of the surface in dark-brown, greenish- 
yellow, or chocolate-tinted spots, which persist from the date of 
one eruption to another. The skin is highly irritable, and the 
most trifling causes are sufficient to induce an attack. In Mor- 
row's case 1 the mere removal of the clothing and exposure of 
the skin of the little patient to the air were sufficient, at the 
time I had the opportunity of observing the phenomena, to pro- 
duce an abundant crop of wheals over the surface. The pig- 
mentation in these cases is probably due merely to the extraor- 
dinary sensitiveness of the integument, whereby repeated and 
rapidly repeated exudations occur in the skin, and the resulting 
maculations are proportioned in depth of color to the frequency 
and intensity of the process. 

1 Archives of Dermatology, January, 1879. 



96 DISEASES OF THE SKI X. 

Four cases of this same disease were exhibited at tlie Inter- 
national Medical Congress in London in 18S1, by Mackenzie, 
Cavafy, and Fox. 

Baker 1 report-; a ease of urticaria tuberosa characterized by the 
presence of persistent yellowish-red tubercles in various parts of 
the body which proceeded to ulceration. The parts most affected 
were the knuckles, elbows, and cars. These tubercles arc said 
to have begun in a manner similar to that which characterizes 
the onset of evanescent urticarial wheals and tubercles. 

Urticaria, like erythema, may be either idiopathic or symp- 
tomatic; and in either, the urticarial condition may underlie or 
be superimposed upon almost every elementary lesion noted in 
the integument. Its lesions may complicate (or be complicated 
by) the macule, papule, tubercle, vesicle, bulla, and pustule. It 
may Bpring from an excoriation, or result in a tissure. It is 
common in traumatisms, and is a prominent symptom in the 
skin bitten by insects, reptiles, and the domestic animals. 

Etiology. — Idiopathic urticaria is occasioned always by the 
action of external irritants. The enumeration of these would 
require a recital of all the external agencies which are capable 
of irritating the skin. Prominent among them are the bites 
and stings of lice, fleas, bed-bugs, flies, gnats, wasps, and bees. 
The wounds thus inflicted usually excite a stinging or burning 
sensation, by which the patient is excited to rub or scratch the 
part. Then a wheal is rapidly formed in the site of the injury, 
and the irritation thus set up is conveyed to other parts of the 
skin in the vicinity, so that, especially in children, a single trau- 
matism by an insect may excite an urticaria covering a much 
larger area. Many medicaments operate similarly; and it should 
be added that some of them, though applied externally without 
toxic effect to the mass of men, may produce urticaria in excep- 
tional cases. Thus a common flaxseed poultice when made to 
cover but a small portion of the body has produced violent 
symptoms of the disease under consideration. 

Symptomatic urticaria is chiefly of the variety named by 
authors, nb ingestis, since it most frequent!}' results from medici- 
nal or dietary articles taken into the stomach. Of the latter class 
maybe named cheese, pork, and confectionery; crabs, lobsters, 
clams, oysters, and fish generally; strawberries, gooseberries, rasp- 
berries ; canned fruits, meats, and vegetables ; pickles, sauces, 
sausage, mushrooms, salads, and spinach. Vinegar, champagne, 
beer, and alcoholic beverages in general are capable of inducing 
a similar effect. Of the former class (medicaments) are the bal- 
sams, the turpentines, quinine, chloral, valerian, arsenic, and 
some of the mineral waters. 

h\ the case of children, a severe urticarial efflorescence may 

1 Lancet, August, 1881, p. 153. 



URTICARIA. 97 

be occasioned by any undigested morsel of food, or indigestible 
material of any sort, which may have been passed into the 
stomach. Thus a bit of orange-peel or fragment of potato paring 
or the skin of grapes, may be discovered to lie at the root of 
the trouble. In the case of adults also who have suffered from 
repeated attacks of urticaria, and have a fully developed sensi- 
tiveness of the gastro-intestinal tract, almost any unusual ali- 
mentary substance, if ingested, will induce a return of their dis- 
agreeable symptoms. 

It must be borne in mind that this undue sensitiveness to the 
effect of ingesta or external irritants is often an idiosyncrasy 
peculiar to the individual either on special occasions or at all 
times, and that, given this susceptibility, the effect is often 
great with a relatively insignificant etiological factor. Thus I 
have seen cases in which a teaspoonful of beer, one grain of 
quinine, the smallest fragment of cheese, and but a single straw- 
berry would not only induce an urticarial rash of such extent 
as to cover the greater part of the surface of the body, but 
would do the same on every occasion when the articles named 
were swallowed in the quantities given. This, it may be use- 
ful to remember, is in general characteristic of the medicament- 
ous eruptions. The a -priori reasoning, that the greater the 
quantity of the toxic agent applied or swallowed, the graver, 
the effect, may lead to gross errors. It should always be re- 
membered, in seeking the explanation for an urticarial rash, 
that the smallest amounts of apparently innocent substances 
may be responsible for the largest annoyance. 

Other causes of urticaria may be cited, such as moral emotions 
(fear, shame, anger) ; gastro-intestinal disorders, where ingesta 
play no part ; malaria ; the erythematous fevers, particularly 
in their prodromal stages; disorders of the uterus, kidneys, and 
nervous centres ; pregnancy, dentition, and the irregularities 
attending the menopause ; and, lastly, the following special 
diseases: asthma, pemphigus, prurigo (of Hebra), rheumatism, 
and purpura. 

Pathology. — The wheal of urticaria is produced by an inter- 
change of play between bloodvessels, muscles, nerves, and tissues, 
under the operation of a principle which the French characterize 
as the choc en retour. There is first, most probably under the 
influence of the vaso-motor nerves, a clonic spasm of the capil- 
laries in a limited area of the derma, by which an acute oedema 
is produced with some serous exudation. The rapidity with 
which this occurs is greater than that with which the tissues 
of the vicinage can accommodate themselves to it either by 
imbibition or more diffuse tumefaction, and there results a 
counter-pressure upon the affected capillaries, by which their 
lumen is still further restricted. As the wheal is not a purely 
fluid-containing nor yet an entirely solid lesion, but is semi- 
fluid in consistency, the mechanical pressure is greatest at the 
. 7 



98 DISEASES OF THE SKIN". 

centre and least at the periphery. Tims is explained the white 
and relatively bloodless appearance of the centre ot* certain 
wheals, and their rosy or reddened outer border. It is con- 
firmed also by the fact that generally the most acute lesions, 
those springing into view most rapidly, are chiefly characterized 
by this whitened centre, while those more indolent, or even 
chronic in their career, have been less subject to the interplay 
of the forces described above, permit of more general vascular 
injection, and have a light crimson or even at times a dull red 
centre. Wheals have been excised and examined microscop- 
ically by Neumann, Poncet, and others, with the result of dis- 
covering merely evidences of infiltration. According to the 
last named author, the lymphatic vessels are also choked with 
"lymph clots." Rone 1 explains the occurrence of the wheal by 
supposing that certain sensitive nerve-fibres of the skin possess 
also a vaso-motor function. 

The process described, occurring as an epiphenomenon after 
the traumatisms or other cutaneous lesions enumerated above, 
merely adds its characteristic symptoms to those previously 
apparent. 

Diagnosis. — The diagnosis of typical urticaria is so readily 
made that it is often recognized as such before the attention of 
a physician is called to it. As usual, the atypical cases are 
those in which confusion may arise. The chief points to be 
remembered are the rapidity of evolution of symptoms, their 
ephemeral character, and the characteristic sensations they 
awaken. The action of the animal parasites and insects not 
parasitic should not be overlooked, and the rash be closely 
examined for the minute wounds inflicted in this way, often 
covered with a minute pin point to pin-head sized dried "blood- 
scale." The various forms of erythema papulatum, tubercula- 
tum, and nodosum are liable to be mistaken for urticaria, but this 
is in many cases inevitable, as the intermediate forms between 
the two disorders are with difficulty assigned to either category. 
Absence of marked subjective sensations and persistence of 
lesions would generally imply the existence of an erythema, 
while marked prevalence of these symptoms would properly 
decide in favor of urticarial disease. 

In many cases the physician is consulted by a patient who 
gives a history of well-nigh intolerable distress at night or at 
other capriciously selected hours, who repeatedly and vainly 
endeavors to exhibit the lesions as they appear upon his skin. 
Being examined on occasions, scarcely a trace of cutaneous 
disorder is manifest. Here the practitioner has to practically 
decide upon the character of an eruption he never sees. The 
task is rarely a difficult one. No other than the urticarial 
eruption behaves in this fashion. Occasionally the physician 

1 Maryland Med. Journ., May 15, 1881. 



URTICARIA. 99 

will discover delicate, rosy, or deeper stained mottlings of 
the surface where the wheals have been but are not. At 
times also he will succeed, on the flexor aspect of the fore- 
arm, or in some situation where the skin is equally delicate, in 
exciting the occurrence of one or more typical lesions by the 
aid of his finger nail in scratching or rubbing. These cases are 
more frequently of the chronic or at least relapsing class ; and 
the victims of the disease may have a characteristic facies, a 
worn look from loss of sleep or mental emotion. One is apt to 
discover in this class those who are mourning over the death of 
relatives, loss of property, separation from home and friends, 
and those harassed by anxieties. 

Treatment. — Many cases of acute urticaria demand no treat- 
ment. The physician is summoned for a diagnosis. The patient 
and his friends are alarmed by the dread of variola or other 
severe affection, and learning that perhaps a pickled cucumber 
is alone responsible for the disorder, they wait with equanimity 
for the conclusion which is always reached. Fortunately the 
exceptionally severe and relapsing forms rarely begin with acute 
symptoms. 

Naturally the first indication to be observed is the removal of 
the cause, and this if possible accomplished, the exclusion of all 
aggravating agencies. The discovery of the cause, at times 
readily effected, is often the most serious problem which is pre- 
sented. An exhaustive and minute examination of the person 
and history of the patient, a study of his food, drink, medicine, 
regime, clothing, sleeping apartment, habits, occupations of life 
and mental state, are here essential. When the disorder is re- 
cent and is an urticaria- ab ingestis, a brisk emetic or cathartic 
may rid the stomach or bowels of offending matters. This done, 
it should be borne in mind that an idiosyncrasy of the patient 
may at this moment render the skin peculiarly sensitive to the 
action of other ingesta, and the diet, for a few days certainly, 
should be carefully prescribed. In many cases the alkalies are indi- 
cated by an acid condition of the stomach, and then the prepara- 
tions of sodium, potassium and magnesium are useful. Laxatives 
such as rhubarb, the cathartic mineral waters, and, in the case 
of children, small doses of castor-oil, are frequently indicated 
when there is no suspicion of irritating ingesta. At other times 
there is marked atony of the digestive organs, when the mineral 
acids, the bitters, and the ferruginous tonics may be needed. 
Again, lactopeptine, pepsine, the subcarbonate or the subnitrate 
of bismuth may be exhibited with advantage for the relief of 
the indigestion which may be the prominent feature of the 
attack. 

Other remedies found useful in the internal treatment of urti- 
caria, are, the arseniate of soda, employed by Blondeau in doses 
of from one-thirtieth (0.002) to one-fiftieth (0.0018) of a grain: 
the sulphate of atropia, given by Schwimmer in doses of one- 



100 DISEASES OF THE SKIN. 

sixtieth (0.001) of a grain: the salicylate of soda, in scruple 
(1.33) doses; and either pilocarpine or the fluid extract of jabo- 
randi. This remedy is known to produce at times a powerful 
effect in relieving surface congestions of the skin, by means of 
the excessive hyperidrosis which it occasions, and in proportion 
to which it may become dangerous. 

The treatment of a symptomatic urticaria should have regard 
also to that disorder of the viscera or general system to which 
the cutaneous symptoms may he attributed. The uterine com- 
plaint of the female may require appropriate treatment, as also 
the diabetes of the patient with an affection of the kidneys. 
Quinine is of course indicated in periodical attacks, but its ac- 
tion in exceptional cases as a direct cause of urticaria should not 
be forgotten. The same, to a greater extent, is true of arsenic, 
the bromide and iodide of potassium, hydrate of chloral, and 
gelseminum. The larger number of patients are best treated 
without the employment of these drugs. 

In the local treatment of urticaria, which is chiefly intended 
to assuage the disagreeable sensations experienced in the skin, 
the greatest diversity exists in the methods employed. This is 
to be largely explained by the fact that a similar difference is to 
be noted in the relief experienced by different patients after the 
application of the same medicinal agent. Thus cold and hot 
water baths, baths medicated by marine salt, aromatic vinegar, 
alcohol, cologne, camphor, the alkalies, and sulphuric ether; 
compresses dipped in such solutions and laid over the part 
affected ; douches and vapor baths will, any of them, in the 
case of some individuals produce a marked alleviation of symp- 
toms; and in others be either inoperative or actually serve to 
aggravate the symptoms in the highest degree. Hebra asserted 
that several of the baths named above are quite useless, while 
Kaposi recommends cold lotions medicated with aromatic vola- 
tile substances. 

The alkaline bath, as prepared in England and America, 
usually contains the carbonate of sodium, the biborate of sodium, 
alum, or the bicarbonate of potassium, either singly or in com- 
bination in the strength of about six ounces (192.) of the salt to 
thirty gallons of water. One or two ounces ^32.-64.) of the sul- 
phuret of potassium may be substituted for these. The water 
is made demulcent by the addition of starch or gelatine, or by 
squeezing into it a bag of muslin containing bran. When it is 
desired to employ the acid bath, half an ounce (16.) of either the 
muriatic or nitric acid is added to the quantity of water given 
above. The bath of this size may be also medicated with one 
drachm (4.) of corrosive sublimate; or this drug may be used 
as a lotion in the strength of from one-fourth (.0016) to one-half 
(.OOoo) a grain to the pint. Carbolic, benzoic, boracic, and di- 
lute hydrocyanic acids in weak solution, are also employed with 
advantage in some cases. Other external applications are, thy- 



URTICARIA. 101 

mol, carbonate of ammonium, bromide of potassium, etber, chlo- 
roform, and chloral camphor in the strength of half to one 
drachm (2.-4.) to the ounce (32.) of ointment. This last is pre- 
pared by rubbing together equal parts of camphor and chloral 
till a semi-liquid substance results. It is an antipruritic remedy 
of some value, but will increase the uneasy sensations produced, 
if not largely diluted. 

In other cases the oily or fatty substances will give more 
prompt relief, especially if the eruption has been much irritated 
by scratching and tends to persist. Among them may be named 
the linimentum calcis of the pharmacopoeia, and cold cream to 
which have been added a few drops of the fluid extract of grin- 
deli a robusta. 

Mention should also be made here of the dusting powders 
which the reader will find described in the chapters relating to 
general therapeutics and the erythemata. They are the most 
cleanly of all external preparations in urticaria, and are often 
the only local measures required. With internal medication, 
as each case may suggest, the practitioner will be careful to note 
that the clothing of the patient is of a character that will not 
aggravate the eruption, that sleep is secured without an excess 
of bed-covering, and that 'places where the temperature is for 
any reason elevated nre carefully avoided, as the proximity to a 
fire-place or drop-light, the opera-house, the kitchen, etc. 

Such is the empirical treatment of urticaria. It will be seen 
to be founded upon no rational method of procedure, and this be- 
cause the very capriciousness of the disease demands and secures 
relief in one instance by a treatment which should be reversed 
in another. It must be admitted that cases occur when all treat- 
ment seems absolutely valueless, often really injurious to the 
patient. These cases will usually be found to be of the relapsing 
or chronic type. The subjects of this form of disease are often 
plunged in morbid mental states ; dreading by clay the exacerba- 
tions of the night; brooding over misfortune experienced or 
anticipated; worn with loss of sleep; fearful of a generous regime 
at the table. Here the treatment is largely moral, and makes 
demands upon the tact and courage of the physician. Travel, 
change of climate, variation in the routine of life, new social 
surroundings, are here valuable. The widow must be made to 
lay aside the heavy crape veil beneath which her urticaria plays; 
the solitary patient must secure a companion capable of diverting 
the nervous attention for a few hours each day. 

Prognosis. — The prognosis of an attack of urticaria is, as has 
been disclosed in what has preceded, exceedingly variable in dif- 
ferent cases. Simple attacks of the acute sort are trivial, and 
in a few days the patient may retain but the slightest souvenir 
of his trouble. In the case of children, the attack is often at an 
end in the course of twenty-four hours. 

It should, however, never be forgotten that urticaria may tor- 



102 DISEASES OF THE SKIN*. 

merit the lite of a patient to the utmost bounds of tolerance, and 
seriously impair the general health. Persistent and rebellious 
chronic urticaria may prove to be a more formidable affection 
than a mild attack of syphilis. 

Eczema. 

Deriv. Gr. I* £i*>, to flow forth. 
Eczema is an acute or chronic exudative affection of the skin, during the course 
of which one or several of the various elementary lesions appear upon the 
surface, either successively or simultaneously, and in either case accompanied 
by a characteristic sensation of itching, the involved tissues becoming mean- 
time infiltrated, resolution occurring in the natural termination of the disease 
"without leaving permanent relics of the process. 

Symptomatology. — Eczema is one of the diseases of the skin of 
most frequent occurrence. In the statistics gathered by medical 
men it would seem to rank first in the order of frequency. But 
this is only true as regards those diseases for which the physi- 
cian is commonly consulted. It is easy to become convinced 
that acne is a more frequently encountered affection than eczema, 
by observation of the faces of individuals on the streets of any 
large city, eczema being of more frequent occurrence in this 
situation than upon other parts of the body. Many persons are 
the subjects of acne who never deem it necessary to submit to 
treatment for its relief, and the records of such cases do not 
figure in dermatological statistics. This being noted, eczema 
may be regarded as the disease of the skin, for which most fre- 
quently the practitioner of medicine is consulted. By as much 
as inflammation is the most common accident of other organs 
of the body, by so much is its enveloping organ subject to the 
same pathological process. 

The surgical signs of inflammation of an} r given tissue are 
usually named as increased heat, redness, pain, and swelling. 
These are essentially the symptoms of an eczema ; and it will 
be necessary, in order to study the disease intelligently, to in- 
quire how these phenomena are modified by the anatomical pecu- 
liarities of the organ in this case affected. A typical eczema is 
always betrayed by an elevation of the temperature of the sur- 
face, and by a greater or less degree of swelling. Redness, in 
varying shapes, is also true of the eczematous skin. Pain here 
is represented by a sensation usually of itching, which may vary 
from slight annoyance to an almost intolerable distress. The 
variation in the sensation which accompanies inflammatory dis- 
orders of the skin and other organs, is merely due to the fact 
that the former is exposed to the air, and its increase in bulk is 
not opposed by other contiguous parts, as, for example, the 
inflamed bone in contact with periosteum, or the pathologically 
enlarged prostate within its fibrous capsule. Inflammation of 
the inner skin of the body, as of the lining membrane of the 



ECZEMA. 103 

stomach or of the intestines, is generally characterized by the 
occurrence of increased heat, redness, swelling, and severe pain. 

Inflammation of tissues constituting other organs of the body, 
usually terminates either in resolution, in the free production of 
pus, or in the occurrence of gangrene. And so an inflammation 
of the skin may terminate either by resolution, or by the free 
production of pus on its surface, the living matter rapidly mul- 
tiplying as the intensity of the process may determine. Gan- 
grene is not a common result of eczema, chiefly because of the 
freely exposed position of the organ affected. 

The great variety of expressions assumed by an eczematous 
disease, and the frequent interchange of these, the one for the 
other, are to be accounted for in the same way. The atmosphere 
which surrounds the body is but one of many external influ- 
ences capable of affecting the skin. Thus it is rubbed and 
scratched, exposed to the friction of the clothing and the incur- 
sions of insects, and subjected to innumerable injurious contacts 
in all the various trades and occupations of life. If the inflamed 
skin could be as perfectly protected from the outer world as is 
the spleen, we should find the history of this affection much 
simplified. 

Clinically, four types of eczema can be recognized. These 
require separate description. It should not be forgotten, how- 
ever, that each may prove to be not a variety, but a stage of the 
disease, which may speedily give place to yet another. 

Erythematous Eczema. 

In this form of the disease the conspicuous symptoms are 
heat, redness, and swelling, with a variable degree of itching, 
usually less severe than in several of the othe. phases of the 
malady. The process may begin with acute and intense symp- 
toms, to be soon followed by one of the varieties of the disease 
to be subsequently described; or, what is perhaps more com- 
monly the case, may continue indefinitely as a subacute, or even 
chronic affection. In color the skin of the part involved varies 
from a light to a darker shade of red ; and inasmuch as the pro- 
cess is more frequently observed in middle-aged adults, with 
darker hue of the integument than in early life, the color of the 
part is frequently noticed to be of a dull shade. In consequence 
of the swelling the affected surface is notably elevated above the 
level of the unaffected contiguous skin, and the line of demar- 
cation between the two can be more readily traced than in sev- 
eral of the other varieties of eczema. The surface is usually 
uniformly and occasionally symmetrically involved. Lesions, 
other than the erythema, which is the prominent feature of the 
attack, are rarely observed ; and as a consequence, from the 
beginning to the end of the disease, there is commonly no his- 
tory of moisture. But in many cases minute poppy to rape seed- 



104 DISEASES OF THE SKIN. 

sized papules become visible on close inspection, still more rarely 
with a very minute vesicular apex filled with a droplet of clear 
Berura. Tiie localities chiefly thus involved are the face, the 
palms, the soles, and the regions about the genitalia, though 

any portion of the body may be involved. Resolution is accom- 
plished after the occurrence of very fine superficial desquamation 
of the epidermis, or by very gradual diminution of the redness 
and swelling without the production of scales. In either event 
the termination of the process is often announced by significant 
changes in the involved surface, as by the fading of color, the 
appearance of islets of sound skin between affected patches, and 
by perceptible relief in the subjective symptoms. 

Such is the course of a typical erythematous eczema. Varia- 
tions from this type are, however, numerous and important. 
Thus the disease may be limited to a patch as small as a finder 
nail, or may extend over large areas, especially after subjection 
to irritation. At times the coloration is irregularly distributed, 
producing a mottled appearance, brighter at one point and 
darker at another; while again, as has been intimated, the 
variety described may coexist with, or be followed by, the 
weeping, excoriation and crusting which are characteristic of 
other manifestations of eczema. Scratching of the part in- 
volved produces a change in the symptoms which the skilled 
eye will promptly recognize. Minute superficial losses of tissue 
are then visible here and there upon the surface ; the fresher 
with a reddened floor possibly hidden beneath a thin blood- 
scale, the older surmounted by a light yellowish-red crust. 
The scratch lines so often recognizable elsewhere are here less 
frequently evident. 

Like all the other varieties of eczema, this is extremely liable 
to recrudescence and relapse. In advanced life, the traces of 
the disease may be visible for years. 

Vesicular Eczema. 

This variety of the disease is, as its name implies, character- 
ized at an early period by the formation of minute vesicles. It 
is a matter of importance, however, to recognize the fact that 
the vesicular, like the erythematous, is but one of several mani- 
festations of this singularly protean affection. Since the ap- 
pearance of the treatises of the early English dermatologists, 
the term eczema has been very generally limited by physicians 
to the vesicular phases of the disease; and it is to the Vienna 
school that we are largely indebted for the recognition of the 
fact that these simultaneous or successive features, presented 
often in the same individual, really belong to one and the same 
malady. To limit the name eczema to-day to the vesicular 
surface alone, would be to relegate the student of diseases of 
the skin to the misty uncertainties of the last half century of 
dermatology. 



ECZEMA. 105 

The clinical features of vesicular eczema are chiefly due first, 
to the acuity of the inflammatory process present ; and second, 
as the result of the former, to the free exudation of the serum 
of the blood from the vascular plexus immediately below the 
pars papillaris of the corium. The involved surface usually 
feels at the outset hot, itchy, or particularly sensitive, and soon 
after becomes more or less intensely reddened, the hyperemia 
producing this effect in the course of a short time giving place 
to a true exudation which may last for one or several hours. 
Poppy- to rape-seed sized vesicles then become visible on this 
reddened base. The lesions may be closely packed together, or 
discrete, or may be so abundant as to coalesce, a frequent be- 
havior of all vesicular lesions. Each is filled with a droplet of 
clear serum, imprisoned beneath the most superficial layers of 
the epidermis. It is readily ruptured, and, if this does not 
speedily occur as the result of accident, it bursts spontaneously, 
and its limpid contents are then poured out upon the surface of 
the integument. The quantity of the fluid thus exuded is in 
excess of that originally contained in the small vesicular cham- 
ber. This is due to the fact that the elevated, macerated, and 
broken epidermis no longer presents an obstacle to the outflow 
of the serum from the engorged vessels beneath. Minute and 
even large drops of a clear fluid of syrupy consistencjr can be 
seen forming at the points where the solution of continuity has 
occurred. If with a slip of bibulous paper the first drop be re- 
moved, its place is visibly filled by a second. Crops of new ves- 
icles succeed the first, each followed by the train of symptoms 
described. The weeping at many points of the surface thus 
affected, is so prominent a feature of the disease that it has led 
several authors of note to describe eczema as a catarrhal disease of 
the skin, an error which is palpable to one who carefully studies 
the affection in each of its several varieties. There are, with- 
out question, forms of the disease where the history is through- 
out entirely different from that just described, where no evi- 
dence of discharge can be appreciated from first to last, and yet 
where, by artificial measures, the so-called catarrhal features 
can be readily produced. 

The subjective symptoms of the vesicular forms of eczema 
are more or less intense itching and often burning. In the very 
acute forms there is considerable soreness, the patient managing 
the affected part with as much care as a fractured limb. In 
exceptional cases, more frequently observed in children, there 
is sympathetic febrile disturbance of a mild grade. 

The discharge from the broken epidermis, whether directly 
from the vesicles or from the vascular elements, dries rapidly 
when exposed to the air, in light yellowish crusts, which are 
rarely bulky. The extent of surface involved is variable, and 
the contour of the affected patch or patches is seldom well de- 
fined, these portions imperceptibly shading into the sound skin. 



106 DISEASES OF THE SKIN. 

The color of tlic area thus diseased varies according to the 
stage of tbe process, being at one time of a bright and vivid 
red. ;it another yellowish, and when covered with crusts or 
Bcales, undergoing a corresponding change of hue. Infiltration 
of the skin occurs rapidly, so that when a portion of the affected 
integument is pinched up between the finger and thumb, it is 
found to be thicker and less elastic than before. 

As resolution approaches, all the symptoms described above 
gradually decline in severity: the serous discharge diminishes, 
the redness fades, the limits of the involved area are less dis- 
tinct, the crusts loosen and fall, and it can be seen that be- 
neath the scales which have taken the place of the oozing and 
broken epidermis, a new and tender epithelial covering has 
been produced. As a rule, for weeks after the process has 
completely ceased, the newly formed epidermis has a slightly 
reddened and tender appearance, though complete resolution is 
followed by no permanent sequelae. 

Such, then, being the typical phases of vesicular eczema, it 
must not be forgotten that clinically the picture may be quite 
different from that described. The types here given are con- 
venient for analysis and study, however they may be com- 
mingled and obscured in the inflamed integument. Like the 
erythematous, the vesicular forms of eczema may precede the 
others, and becoming chronic, torment the suffering patient 
continuously for long periods of time, or yield, only to reappear 
at irregular intervals. 

Pustular Eczema. 

This variety of the disease may originate in one of the other 
forms of eczema, which, in consequence of the severity or acuity 
of the process, changes from an erythematous, papular, or more 
commonly vesicular type, or the pustular lesions may rapidly form 
at the onset. Usually a crop of minute vesicles is first seen of 
the sort just described, which, after enlarging to the size of a 
coffee bean, become distended with puriform contents. These 
either accidentally or spontaneously burst, and the fluid with 
which they were distended dries into yellowish-green or darker- 
colored and friable crusts. In aggravated cases the purulent 
matter seems to form directly upon the surface involved. If 
the process be long continued, infiltration occurs; and the itch- 
ing, which in all varieties of the disorder is a characteristic 
feature, is awakened as an accompanying symptom. It is, how- 
ever, rarely of the peculiarly aggravated type which accompa- 
nies the erythematous and papular phases. Pustular eczema is 
most frequently encountered in the regions of the head, and in 
constitutions where there is a pyogenic tendency. When exist- 
ing on the scalp and face there is most commonly an involve- 
ment also of the sebaceous glands, whose secretion, altered by 



ECZEMA. 107 

the periglandular 'inflammation, is added to that naturally pro- 
duced by the exudative process. Singular shades of mixed, yel- 
low and green, and even black, are then to be distinguished in 
the resulting crusts, which later desiccate and fall, leaving a 
reddened and tender new epidermis beneath. 

Pustular eczema, as thus observed, has been described under 
a great variety of titles. Its identity as a form of eczema was 
first accurately distinguished by Hebra, in his experiments on 
the artificial production of the disease upon the surface by the 
external application of croton oil. It has been called impetigo 
figurata, mellitagra, porrigo larvalis, and other singular names, 
which suggest the attempts of the early astronomers to name 
the constellations by their resemblance to the figures of animals. 
These and many other useless terms have been finally dropped 
from the nomenclature of modern dermatology. 

Papular Eczema. 

Under this title are classed all those forms which have long 
been described as lichen eczematodes, eczema lichenodes, etc. 
" Observation of the natural course of an attack of eczema," 
says Hebra, "furnishes the most unassailable proof of the con- 
nection between its various forms. In one case an eruption of 
vesicles begins the series of symptoms; in another, it is preceded 
by the appearance of red scaly patches or groups of papules; or 
vesicles and papules are developed together, some of the former 
rapidly changing to pustules, and forming yellow gum-like 
crusts by the drying up of their contents." It is of the greatest 
importance that there should be a distinct and more general 
recognition of the fact, that eczema may exist from first to last 
as a dry infiltration of the integument, for there is perhaps no 
one of the various manifestations of the disease that is so fre- 
quently mistaken, and confounded with other widely different 
affections. 

The poppy- to rape-seed sized papules, which are developed in 
its course, are usually seated upon a reddened and thickened 
base, and are themselves colored in various shades of red to a 
dark lurid shade. They are usually discrete, though often closely 
set together; are accompanied by a severe form of itching when 
irritated by scratching; and of all eczematous lesions are most 
apt to be thus irritated. Their summits are torn, and often to 
such an extent as to bleed, the blood drying in reddish crusts 
over the area involved or limited to minute blood scales on the 
apices of individual lesions. The extent of surface affected 
varies, as usual in the other varieties, being in cases largely dif- 
fused in patches over various portions of the body, or limited 
to small and single patches no larger than a silver quarter of a 
dollar. Such patches covered with a single or several groups 
of reddish papules may continue to torment the patient for long 



108 DISEASES OF THE SKIN. 

periods of time, or, being at one time relieved, recur with eaeh 
aggravation of the part by the exciting cause. Papular eczema 
is the dry manifestation of the disease, and is thus most fre- 
quently noticed upon the drier portions of the integument. 

These are the surfaces of the limbs, the back of the body, and. 
in particular, the scrotum. In the latter region the lesions o;iv- 
ing a name to this variety of the disease are most fully devel- 
oped. If the moist forms of eczema are most frequently seen in 
early life, it is none the less true that the dry forms are most 
common in adult life or advanced years. 

It should not, however, be forgotten, that the papules here 
described may develop into minute or larger pustules, or may 
exhibit minute vesicular summits when there is free exudation 
beneath the surface. It should be added, that a patch of papu- 
lar eczema, where no vesiculation nor pustulation has been 
observed, will, if sufficiently scratched, ooze with moisture, the 
serum escaping from the abraded surface. There are, in fact, 
few scratched eczematous surfaces which will not moisten a dry 
handkerchief applied to the part. This weeping condition 
attracts the attention of patients themselves, who will complain 
of it in describing their symptoms to a physician. A certain 
species of relief for the pruritus is thus obtained; and in aggra- 
vated cases patients will scratch or rub or otherwise irritate 
their diseased patches, not merely for the purpose of gratifying 
the intense desire to assuage this symptom, but alsoto induce 
the serous exudation for the sake of the relief it affords. The 
secretion when in contact with linen cloths stains and stiffens 
them, very much as seminal fluid leaves its traces upon the 
clothing. 

Resolution of papular eczema is accomplished after the for- 
mation of scales, the tissue beneath the latter assuming more 
and more the appearance of healthy skin. 



The four types of eczema considered above are, as has been 
stated, sometimes encountered in practice as distinct and un- 
mingled forms of cutaneous disease, some of them more com- 
monly than others. To present, however, a picture of eczema as 
it is seen clinically, it must be understood that these several 
forms, useful in the analytical study of the disease, often become, 
in actual observation, well nigh inextricably commingled. It is 
this untiring interchange of features which distinguishes all 
the results of manifold causes operating in nature at one and the 
same time; and it this which gives the inflammations of the 
human skin, exposed to almost every external influence, such a 
manifold physiognomy. 

Like all other inflammations, eczema may be acute or chronic. 
Like all others, too, the acute may precede, and the chronic fol- 
low ; or the reverse may occur, the disorder, originating in sub- 



ECZEMA. 109 

acute or insidious forms, may become chronic, and then, as the 
result of fresh or more severe irritation, develop into the acutest 
symptoms. Thus the name eczema rubrum has been given to 
the red and angry form of the disease, which, because of the free 
exudation of serum from its surface, has been also termed eczema 
madidans. In this form, the intensely red and wounded integu- 
ment pours out freely upon the surface a thick gummy or syrupy 
fluid, which, if artificially removed, leaves behind it the swollen, 
angry, and still discharging skin, or, being permitted to dry 
where it has formed, concretes into the thick, dark-colored and 
often blood-stained crusts already described. 

Again, the scales which usually form on the eczematous skin 
toward the conclusion of the process just described, may prove 
to be the most characteristic feature of the case from the first. 
Thus on the back of the neck an eczematous patch may often 
be seen, where the skin is infiltrated, and covered with a stratum 
of thin, whitish scales, the latter having developed rapidly upon 
an erythematous surface, and continuing for a long period as a 
scaly disease. It is to this and similar forms that the term 
eczema squamosum has been applied. Again, in the regions 
about the hand, the movements of that organ develop often fis- 
sures or cracks in the inflamed and infiltrated integument, and 
to these fissured- forms the term eczema fissum has been applied. 
They are observed wherever an eczematous disorder has so im- 
paired the elasticity and extensibility of the skin, that its neces- 
sary movements, especially about the joints, tear and stretch the 
torn integument. It is thus seen not only in the hands, but also 
in the feet and about the ankles, the resulting rhagades being 
at times probably the most painful of all the complications of 
the malady. Occurring in the bodies and upon the hands of 
those who are. compelled to come into contact with irritating 
substances, this form of the disease finds its severest expression. 

Eczema Intertrigo 

Is a name applied by several authors to that form of intertrigo 
which, surpassing the limits of hypersemia, results in an exuda- 
tive process. Reference was made to this possibility in describing 
the symptoms of erythema intertrigo, in a preceding chapter. 
Here the symptoms are usually those of diffused redness of sur- 
faces of the skin in close apposition, macerated by previous 
transudation of sweat, and weeping with the serum which oozes 
from the several abraded points or patches. 

Eczema Verrucosum, 

Or the wart-like form of the malady, is occasionally observed, 
especially upon the lower extremities, in middle life or advanced 
years, as the result of long-continued disease. The integument 



110 DISEASES OF THE SKIN. 

becomes thickened and so hypertrophied as to suggest the ap- 
pearance of warts closely packed together in a circumscribed 
patch. 

Eczema Sclerosum 

Is a form of the disease most frequently observed upon the 
palmar and plantar surfaces, a condition referred to in the para- 
graphs relating to asteatosis. Here there is present a densely 
thickened inelastic integument, suggesting the condition of 
tanned leather, without the occurrence of any of the other 
lesions of eczema described above. As a consequence the perfect 
extension of the digits is impaired. 

Most authors agree in considering eczema as it occurs in its 
acute and chronic manifestations. These are, as has been inti- 
mated, interchangeable conditions, the types of which possess, 
however, a clinical distinctness. 



Acute Eczema. 

In certain cases an acute attack of the disorder is ushered in 
by malaise, chilliness, or the recognized symptoms of the febrile 
state. With or without these prodromata, the affected portion 
of the surface speedily gives rise to a burning sensation, which 
is soon succeeded by redness and swelling. This may occur upon 
one or several portions of the body at the same moment of time, 
and the disease throughout be limited to this single area or 
those several spaces ; or it may extend from one or all to other 
regions. This process of extension may, by continuous devel- 
opment of the disease along the surface, or an eczema of the 
thigh, be suddenly followed by an eczema of the face, and this 
by an eczema of the scrotum. According to Kaposi, extension 
of eczema by the last-described method is due to the extraordi- 
nary sensitiveness of the skin when involved in an acute attack, 
in consequence of which the slightest friction and even reflex 
irritation of the bloodvessels produce a new focus of the dis- 
ease at a distant point. 

This seems to me a consideration of special importance. Pa- 
tients will frequently point to an acute eczema upon several 
[tortious of the body widely separated, the one from the other, 
and urge this as an irrefutable argument in favor of the fact 
that they suffer from some "poison in the blood." 

The tumid and erythematous surface already described soon as- 
sumes the features of either papular or vesicular eczema, which 
need not be again detailed. In this manner the evolution of 
the disease occurs, and may continue for weeks, the patient, if 
unrelieved, tormented by the itching; and, if the disease be ex- 
tensive, prevented from attending to his usual avocations. Acute 
eczema of severe grade will frequently prostrate a strong adult, 
contininor him to his bed-chamber, and often to his bed. When 



ECZEMA. Ill 

there is a simultaneous febrile process, the emaciation and adyna- 
mia are proportioned to its severity. Weeks, and even months, 
may elapse before recovery can be pronounced complete, sub- 
acute patches of the disease lingering here and there upon the 
surface, crust-hidden, scale-covered, occasionally oozing from 
recrudescence of symptoms. Recovery, even when complete, 
leaves the patient, it should never be forgotten, with a skin sen- 
sitive to irritation and more prone to a fresh attack of the dis- 
ease than one long virgin of an inflammatory process. 

Such is the course of an attack of acute eczema of severe grade, 
heedless to say that a circumscribed patch of the skin may ex- 
hibit all the features of vesicular eczema in an acute form; and, 
under the influence of appropriate treatment, be satisfactorily 
relieved in the course of a few days. Lastly, acute eczema may 
be followed by chronic forms of the disease, the one passing into 
the stages of the other by scarcely definable gradations. 

Chronic Eczema. 

The symptoms and pathology of chronic eczema are largely 
those of the acute form of the disease. The chief differences to 
be noted relate to diminished intensity of the inflammatory ac- 
tion, or marked tendency to persistence of the process, and a 
preponderance of scaling and infiltration as contrasted with the 
active secretion and crusting of the acute phases. It is, however, 
important to remember that chronic eczema is not only the fre- 
quent sequel of such acute phases, but is particularly prone to 
recurrent exacerbations of acute grade, during which the serous 
discharges, consequent crusts and angry aspect of the affected 
surface, do not fail to reappear. The itching so characteristic 
of the malady in all its manifestations is here also a tolerably 
constant symptom. 

Chronic eczema may involve a limited surface of the skin, or 
invade the entire surface of the body from the head to the feet. 
Rarely thus generally developed, it is more frequently observed 
upon circumscribed patches of the integument, as, for example, 
the scrotum or the flexor surface of a joint, in which situation it 
may linger for years, or even for a lifetime, now better and now 
worse, or disappearing for brief periods only to return with each 
recurrence of its cause. 



Etiology. — Eczema is a disease of both sexes and of all ages ; and 
is, moreover, neither contagious nor inherited. The study of 
its etiology is thus to a degree simplified. 

In many cases no cause of eczema can be discovered, beyond 
those which operate exclusively within the skin-organ and are 
proper to itself. These are necessarily obscure, and will remain 
so until we are in possession of far more knowledge as to the 



112 DISEASES OF THE SKIN. 

complex mid inscrutably delicate processes by which innervation, 
nutrition, and new formation of the living matter of the skin, 
are both conserved and impaired. The autonomy of the integu- 
ment imi-i be conceded to the extent recognized in other organs 

of the body. There are diseases of the liver which are neither 
referred to the blood, the nerves, nor to the action of poisons. 
There arc diseases of* the heart which can neither be induced by 
rheumatism nor syphilis. When the etiology of the disorders 
of all the viscera is perfected, that of the skin displaying the 
lesions of eczema will be assuredly more distinct. 

These remarks are justified by clinical facts. Eczematous 
affections occur in the persons of individuals who are in every 
respect superb examples of good health, where the most thorough 
and careful examination fails to reveal for the disorder either an 
external or internal cause. Eczemas occur also in persons who 
are affected with wavy form of bodily ailment; those suffering 
from acute and chronic disorders of every viscus and system of 
the body; and even those affected with other disorders of the 
skin. This is only what a study of established facts would sug- 
gest, having in view the probable proportion of eczematous at- 
tacks in every thousand individuals. Such coincidences would, 
however, scarcely furnish a satisfactory etiological basis for the 
disease, unless a certain degree of constancy between eczema and 
these disorders could Jbe established. Thus eczema is often seen 
in patients affected with rheumatism, gout, dyspepsia, malaria, 
obstinate constipation, anaemia, scrofula, and pulmonary disor- 
ders, a list of affections exhibiting surely very wide pathological 
differences. Yet he would prove to be a physician of exceedingly 
limited experience who could not select from patients under his 
own observation, twenty individuals affected with any one of 
the diseases named, no single person of the entire number having 
ever exhibited symptoms of eczema. If figures alone were to 
decide the question, these and a larger list of maladies which 
have been named in similar connection, would be excluded in 
the study of the etiology of the disease. 

This much premised, it should be added that every phase of 
eczema can be artificially produced upon the surface of the skin 
by the action of external irritants. Several authors, notably 
those of French nationality, take exception to this view, claim- 
ing that the induced disease in such instances is an artificial 
dermatitis, but they fail to point out the distinctive objective 
differences between such dermatitis and eczema. They content 
themselves with observing the subsequent evolution of the 
malady, and pronounce that to be an eczema which fails to 
respond promptly to treatment; and that, a dermatitis which is 
capable of speedy relief. The climax of such absurdity is reached 
when they are shown obstinate cases of eczema of artificial origin, 
and the response is, that the induced dermatitis gave rise to an 
eczema in a predisposed subject. 



ECZEMA. 113 

One step further and we are in position to estimate the approx- 
imate value of the etiological factors in eczema. The large 
majority of all generall} T recognized and externally operating 
causes of the complaint, fail to have such an effect in the mass 
of individuals. Whether any one of them be necessarily fol- 
lowed by the disease is open to some question. Even the poison 
ivy, a fertile source of the disorder in susceptible individuals, 
will fail to influence others. The late and eminent Professor 
Boeck, of Christiania, when he was last in America rubbed the 
tender leaves of this plant over his hands and face in repeated 
efforts to produce the disease in his own person, and utterly 
failed of the desired end. 

Respecting the numerous agencies operating thus externally, 
and capable of producing the disease under consideration, it is 
to be remarked that they can all be referred to either; solar 
light and heat; contact with foreign bodies in various vaporous, 
fluid, or solid states; toxic agencies of a widely differing nature; 
traumatisms in varying degrees; and the action of parasites. 
Many of these co-operate; some include others; and some be- 
come effective by aggravating a disease which others have en- 
gendered. The reader is referred to the chapter on general 
etiology for fuller consideration of this subject. It will be suffi- 
cient to note here that acids, alkalies, antimonial and mercurial 
compounds, mustard, sulphur, castor oil, capsicum, arnica, tur- 
pentine, chloroform, ether, alcohol, and a long list of other medi- 
caments are capable of producing eczema when applied to the 
skin externally. The same is true of articles manipulated in 
many of the trades, those, for example, handled by the grocer, 
the baker, the confectioner, the seamstress, the ink manufac- 
turer, the mason, the cook, the gardener, the laundress, the 
painter, the dyer, the printer, the tobacconist, and the chemist. 
Then, too, the eczema of the person exposed to intense cold, or 
intense solar light and heat, aided by reflection from the water, 
or even by excessive artificial heat, as the fire of a furnace, illus- 
trates the action of other causes named. Pressure and friction- 
effects are exhibited in the eczema produced by the contacts 
with gaiters, cuffs, trusses, saddles, crutches, and corsets. 

Scratching is a fruitful cause of eczema when the skin is 
affected with pruritus as a distinct disease, or as a symptom of 
other cutaneous disorders. Thus it is efficient in urticaria, 
scabies, and the prurigo of Hebra; in the skin bitten by lice, 
insects, bed-bugs, and fleas (which even without such interfer- 
ence are capable in many cases of inducing the disorder); and 
in the lower extremities where the skin is distended by varicose 
veins. 

Water is capable of exercising an injurious effect upon the 
skin to the extent of producing an eczema, whether it proceeds 
from the sudoriparous gland in an excessive exudation of sweat 
which is not duly removed by ablution ; or be applied externally 



114 DISEASES OF THE SKIN". 

as a fluid in excessively cold or hot temperatures; or in the vapors 
of the popular Turkish and Russian baths; or yet again be ren- 
dered irritating by its saline or other constituents. 

The external sources of eezernqtous trouble named above 
should he regarded simply :is suggestive illustrations. It should 
be borne in mind that every contact with the external world, 
sufficiently severe or prolonged to awaken the resentment of the 
healthy skin, may be followed by the protest of the latter in the 
shape of an eczema; and the same may be true when even the 
most trivial external accidents occur to the sensitive skin of 
certain individuals particularly prone to the disease. 

Turning to the so-called internal causes of eczema, these must 
be, for reasons already detailed, considered for the most part as 
either coincidences or conditions which favor the development 
of diseases in general, eczema not excepted. By interference 
either with innervation, nutrition, development, excretion, or 
the performance of the important functions of the body, as well as 
by reflex irritation of the surface, they operate by inviting, aggra- 
vating, or prolonging an eczematous disease. Among these may 
be named: as diseases, rheumatism, gout, struma, gastro-intestinal 
derangements, including dyspepsia, constipation, and functional 
disorders of the liver, chlorosis, and menstrual disorders; as 
physiological states, pregnancy, lactation, and dentition; as 
associated with the habits of life, occupations necessitating in- 
ordinate fatigue of body or mind, especially with the exclusion 
of sunlight; and lastly, as originating in the irritative action 
upon the mucous surfaces, of substances foreign to the body, 
dietary, and medicinal articles capable of exciting cutaneous 
rashes, intestinal parasites, and instruments inserted and fluids 
injected into the mucous canals, as, for example, the male 
urethra. 

Pathology. — The pathological changes in eczema are those of in- 
flammation of the skin, varying somewhat with the acuteness or 
chronicity of the process and the character and career of the exu- 
date furnished in each expression of the disease. In all cases there 
is, first, a circumscribed or diffused hyperemia of the affected 
part. This results from a series of more or less rhythmical and 
alternate dilatations and contractions of the vascular capillaries, 
the apogee of which is persistent vascular distension, blood-stasis, 
and the condition generally recognized as engorgement of the 
affected parts. This engorgement becomes visible to the eye in 
various shades of increased redness. Then occurs an exudation, 
by which a material in various degrees of fluid or solid consist- 
ency is added to the tissues. This process is also coarsely appre- 
ciable, either by the free ooze of serum from the surface; or by 
the imprisonment of such exuded fluid in the chambers of the 
vesicles which it produces; or by an increased thickening of the 
various constituents of the skin, perceptible when these are 
pinched up between the finger and thumb; or, lastly, by the 



ECZEMA. 



115 



appearance of various solid or semi-solid projections concerning 
the skin proper, or, secondarily, its glandular appendages, which 
visibly spring from the involved area. Thus are explained the 
various erythematous, vesicular, pustular, and papular manifes- 
tations of eczema. 

A history of the many doctrines which have been held regard- 
ing the part played in these phenomena by the bloodvessels, the 
nerves, and the tissues would simply exhibit the several steps 
which have been taken in arriving at the facts now demonstra- 
ble. The researches of Heitzmann serve to throw light upon this 
inflammatory process in the skin in a highly satisfactory way. 




/_--_.- • - <<*&»" 



Chronic eczema — vertical section of the skin of the forearm, a, epidermis ; 5, thickened rete; 
e, hyper-pigmented layer of rete ; d, enlarged papilla;; e, atrophied sebaceous gland ; /, atro- 
phied hair follicle ; g, infiltrated corium. (After Kaposi.) 

As to the part played by the epithelium, Heitzmann 1 shows 
that the initial step of the inflammation is declared by an in- 
crease of the living matter, both within and between the proto- 
plasmic bodies; the former produces a coarse granulation of the 
epithelia due to increase of living matter. This increase is evi- 
dently due to augmented afflux of nutritive material in the 
stage of hypersemia. It is declared at the points of intersection 
of the protoplasmic network (the formerly so called granules) 
by their enlargement, and by the shining and solid condition of 

1 Transactions Arner. Derm. Association, Fourth Annual Meeting. 



116 DISEASES OF THE SKIN. 

that part of the network formerly called "the nucleus." The 
increase of living matter between the protoplasmic bodies is 
declared in a thickening of tlie threads traversing the cement- 
substance. Every particle of the living- matter, either within 
or between the epithelia, is capable of producing a new forma- 
tion of epithelial elements. Thus is explained the part played 
by the epithelium in the thickening of the skin, the production 
of scales in squamous eczema, etc. 

In connective tissue, the first, manifestation of the inflamma- 
tory process is the dissolution of the basis-substance and reap- 
pearance of the protoplasmic condition; by this process and the 
new formation of medullary elements which may start from any 
particle of living matter, the inflammatory infiltration is estab- 
lished. The sum total of the inflammatory elements which 
remain united with each other by means of delicate off-shoots, 
represents an embryonal or medullary tissue. In the case of 
erythematous eczema, the new formation of medullary elements 
is scanty, and resolution is accomplished by reformation of the 
basis-substance. 

In papular eczema the papilla? of the skin are enlarged in all 
diameters, partly owing to a dilatation and enlargement of their 
capillary bloodvessels, and partly to the peculiar connective 
tissue changes already described. Plastic formative inflamma- 
tion may be accompanied by the accumulation of a larger 
amount of serous or albuminous exudation in the epithelial 
layer as in vesicular eczema. 

Suppuration in the epithelial layer of the rete mucosum is 
produced by the accumulation of an albuminous or fibrinous 
exudation, in consequence of which a number of epithelia are 
destroyed, and by a new formation of pus corpuscles from the 
living matter of the epithelial elements themselves. Epithelial 
suppuration of this sort is not followed by a cicatrix. This is 
the pathology of eczema pustulosum and eczema madidaus. 

The elevation of the temperature in the inflamed skin is some- 
what proportioned to the rapidity of the process. In acute 
eczema such elevation may exceed 105.5° F. (41° C), while in 
chronic eczema it can scarcely be appreciated. 

The fluid exuded in eczema, whether taking part in tumefac- 
tion of any portion of the skin, as in vesiculation ; or in a free 
discharge from the surface, is always identical. It. is a yellowish- 
white sticky and syrupy liquid, feebly alkaline in its reaction, 
depositing albumen in abundance when treated by heat and 
nitric acid, and exhibiting the characteristic features of the 
serum of the blood under the microscope. Exposed to tlie air 
it desiccates in light yelloAvish to brownish, friable crusts, which 
resemble honey or gum. 

Increase in the pigment particles distributed to the epithelia 
of the rete is characteristic of the chronic forms of eczema, and 
more .especially of those where the circulation is somewhat ini- 



ECZEMA. 117 

peded by the influence of gravity, {is, for example, in the lower 
extremities. This is true, however, of all diseases accompanied 
by an augmented afflux of blood to any part of the body, as, for 
example, over the surfaces of joints to which for many years 
stimulating embrocations have been applied. 

Diagnosis. — Eczema is such a protean disease in its manifesta- 
tions, and is, moreover, of such frequent occurrence, that it is 
necessary to establish a differential diagnosis between it and a 
large number of other cutaneous disorders. The more important 
of these are named below in alphabetical order for convenience 
of reference, the distinctive differences of each being briefly 
appended. It must be remembered, however, that the identity 
and characteristics of eczema are made clear only after a close 
study of all its features; and that this is the surest basis for an 
accurate diagnosis in every case. 

Acne. — Acne occurs chiefly on the face, neck, and back of the 
trunk, and its pustular forms might be mistaken for eczema of 
the same localities But pustular acne is usually accompanied 
by a deeper seated infiltration than the similar lesions of eczema; 
and this infiltration is also generally limited to the sebaceous 
glands or periglandular tissues. In eczema the itching is often 
severe, while in acne the subjective sensations are those of heat 
or burning; comedones intermingled with the pustules of acne 
will aid in distinguishing the two. 

Erythematous eczema of the face is to be distinguished from 
acne rosacea by its more generalized infiltration, its production 
of itching, and its greater diffusion over the face; while acne 
rosacea is more often limited to the face, nose, brow, and the re- 
gions adjacent to these parts. The patch of erythematous eczema 
is " hot ;" that of acne rosacea, "cold" to the touch. The former 
is seen in infancy ; the latter is rare in that period of life. Acne 
rosacea is also in many cases readily distinguished by the devel- 
opment of visible bloodvessels in the skin of the cheeks or nasal 
region. Lastly, in erythematous eczema the lids are apt to 
suffer, while in acne rosacea this is the exception. In severe 
forms of acne the sub-epidermic pus formation and the resulting 
sear will prove significant. 

Dermatitis. — Dermatitis, of artificial origin, is to be distin- 
guished from idiopathic eczema rather by its history than by 
special differences in the appearance or evolution of lesions. In 
many cases the two affections are indistinguishable. A history 
of traumatism or of the external application of irritant or toxic 
articles will often serve to distinguish the two. Dermatitis of 
artificial production is usually sudden in its onset, the date of 
which will nearly correspond with the time of the operation of 
the exciting cause. The subsidence of the symptoms after the 
withdrawal of the cause will also point to the nature of the 



118 DISEASES OF THK SKI.V. 

affection. Eczema is also much more capricious in its distribu- 
tion and career. 

Erysipelas. — Erysipelas is generally accompanied by febrile 

symptoms, ;ui<l in many cases by bullae. The affected surface is 
reddened, much more swollen than in eczema, and exhibits be- 
Bides a characteristic shining appearance, which is always absent 
in erythematous eczema. The line of demarcation between the 
affected and unaffected portions of the skin is usually distinctly 
defined in erysipelas, ill defined in eczema. Erysipelas spreads 
from one point to another with a rapidity which is never noticed 
in eczema. In the latter disease also, when occurring upon the 
face in the erythematous form, the scalp is usually spared, while 
erysipelas tends to invade the scalp and the regions covered by 
the beard of the male. 

Erythema. — Eczema is to be distinguished from the forms of 
erythema which are due to hyperaemia only, by the presence of 
an inflammatory process. The erythema simplex which ad- 
vances to exudation, at once transgresses the artificial line of dis- 
tinction between the purely congestive and purely exudative 
disorders. It must therefore be remembered that many eczemas 
begin as erythemata, and that, clinically, the latter may repre- 
sent but a stage in the disease process. The discharge in ery- 
thema intertrigo results from imprisoned or chemically altered 
sweat, and will not stiffen linen, as does the serous exudation of 
vesicular eczema, for example. Erythema multiforme, an affec- 
tion really on the border line between the two pathological 
classes here sought to be distinguished, will be recognized by 
the absence of severe itching, and the recurrence of the disorder 
at certain special seasons of the year; while E. papulosum, EI. 
tuberosum, and E. nodosum, display solid elevations of the sur- 
face much exceeding in size the minute lesions of papular eczema. 

Herpes. — Eczema is, in the minds of many, so associated with 
the occurrence of a vesicle, that other'vesicular disorders are apt 
to be confounded with it. But in herpes febrilis, the vesicles 
are usually grouped about the mucous outlets of the body, and 
when actually under observation, usually exceed in size the 
minute and transitory lesions of vesicular eczema. In herpes 
zoster with the limitation of the eruption to one side of the body, 
there is also a history of 'precedent neuralgic pain, with a possi- 
bility of the subsequent production of scars. 

Impetigo and Impetigo Contagiosa. — In these forms of disease 
the pustular lesions are usually isolated, do not spring from an 
infiltrated surface where other lesions may be visible, and are 
unaccompanied by the intense pruritus which is characteristic 
of eczema. The pustules, moreover, are larger, and the resulting 



ECZEMA. 119 

crusts, as a rule, bulkier and darker colored than in eczema. 
Again, in pustular eczema the cutaneous affection usually occurs 
in one or more patches, while in impetigo a dozen or more iso- 
lated pustules may be irregularly scattered upon the entire sur- 
face of the bod}^. In the contagious form of impetigo, there 
may be a history of the extension of the disease from one mem- 
ber of a family to another. 

Lichen Ruber. — Here the dull red, non-excoriated papules, 
covered with minute scales, unattended by severe itching, and 
occurring especially upon the limbs, could scarcely be mistaken 
for the vivid, angry, and scratched papules of eczema, which, 
moreover, are often accompanied by secretion from the surface. 
When the scales covering patches of coalesced papules in lichen 
ruber are removed, the orifices of dilated hair follicles become 
visible. This is never true of papular eczema. But the im- 
portant symptoms of a grave disease in lichen ruber, such as 
marasmus and the indications of a fatal termination, will not 
fail to attract attention. 

Lupus. — Lupus vulgaris is readily distinguished from eczema 
by its more chronic career, its larger papules and tubercles of 
dark reddish-brown hue, and by every one of its destructive pro- 
cesses, none of which are ever recognized in eczema. Lupus 
erythematosus, however, greatly resembles certain forms of 
squamous eczema. Here the greater chronicity of lupus; the 
firm attachment of the scales; the symmetrical distribution of 
certain patches upon the face; the association of the disease with 
the sebaceous glands ; the definite border of each involved area; 
and, above all, the discovery of the cicatrix where it has existed, 
will sufficiently distinguish the disorder. 

Pediculosis.— As eczema is often induced by lice upon the 
head, pubes, or clothing, it is always necessary to exclude the 
operation of such causes both for diagnostic and therapeutic 
purposes. Eczema, limited to the pubic region or existing there, 
and elsewhere only about the axillae, should suggest careful ex- 
amination of the skin and hairs for the discovery of the crab 
louse. As for the pediculus vestimenti, it should be the rule of 
the physician, invariable and never to be forgotten (whatever the 
social position or refinement of his patient), to search for evi- 
dence of the parasite upon the under surface of the clothing worn 
next the skin, at the instant of its removal and while the patient 
supposes him to be busied with the inspection of the cutaneous 
lesions. The excoriations produced by scratching wounds in- 
flicted by body lice are usually out of all proportion to the 
amount of skin disease present ; and this is the most significant 
of all symptoms next to the discovery of the corpus delicti. Head 
lice may precede or follow eczema of the scalp, but either they 



120 DISEASES OF THE SKIN. 

or their ova (nits) clinging in numbers to the hairs will be visible 
to him who looks carefully for them. 

Pemphigus and Pityriasis Rubra. — The large isolated bullae 
of pemphigus vulgaris arc never seen in" eczema. In pemphigus 
foliaceus the lesions are succeeded by the formation of pastry- 
like crusts with the eventual production of an extensive and 

usually fatal exfoliative dermatitis. The marasmus becomes 
then rapidly conspicuous, while as a rule itching and infiltration 
are not present. The disease.- known as pityriasis rubra is equally 
rare and fatal ; and, though unattended with the production of 

bullas, is characterized by an equally abundant epidermic exfo- 
liation, itching and infiltration being either entirely wanting 
or of insignificance in comparison with the other symptoms 
present. Both diseases are particularly liable to be complicated 
with chills or uncontrollable diarrhoea. It is proper to remark 
here that, without question, many of the reported cases of so- 
called pityriasis rubra are instances of squamous eczema. Here 
the localization of the disease to one or more patches upon the 
body, the severe itching and the distinct infiltration of the patch, 
will point to the eczematous character of the disease. Observa- 
tion of such patients will finally convince the observer, in many 
cases, that there is occasional weeping from the surface. 

Prurigo and Pruritus. — In the prurigo of Hebra, a disease 
exceedingly rare in this country, there is infiltration, intense 
itching, and numerous minute papules. But the disease usually 
occurs within a year or two after birth, and lasts lor a lifetime, 
extending generally over the greater part of the body, sparing- 
only the palms and soles (which eczema does not), and is accom- 
panied by inguinal adenopathy. In pruritus, often confounded 
with prurigo, there is itching without disease of the skin save 
that induced by the nails to relieve the sensation. Hence pru- 
ritus without scratching will not reveal a cutaneous disease; 
while the same disorder with scratching will exhibit either ex- 
coriations, or an eczema induced by the attacks made upon the 
skin. The last is, however, rarely noted. The distinction will 
be clear when it is remembered, first, that pruritus is usually of 
a paroxysmal character, worse regularly at certain hours or 
seasons; second, that pruritus not originating in a cutaneous 
lesion, but indirectly producing the latter by the medium of the 
nails, never exhibits as much cutaneous excoriation as the skin 
bitten by lice or attacked with eczema. The impressive symp- 
tom here is always the disproportion between the complaint of 
the patient and the visible symptoms. 

Psoriasis. — Psoriasis and eczema in typical forms are distinct. 
Variations from type in the direction from the one to the other 
furnish many obscure cures. 



ECZEMA. 12L 

The following are the chief diagnostic points: In psoriasis, 
definition of contour of patch ; abundance and lustrous hue 
of scales ; absence of moisture; vascularity of tissue beneath 
the scales ; sites of election on extensor surfaces of limbs ; 
chronicity in course; uniformity of lesions, and absence of 
itching. In eczema there is an ill-defined contour; usual!}' 
scantj* scales not having a nacreous hue ; a preference for 
the flexor surfaces of the extremities, though the disease may 
occur in any portion of the body; generally, at some period 
in its course, a history of moisture ; polymorphism, as regards 
lesions, and a marked intensity of objective sensations. Upon 
the scalp, psoriasis is particularly apt to extend beyond the 
hairy border in a fillet stretching across the upper portion 
of the forehead and. thence irregularly down in front of the 
ears ; while eczema of the face, when the scalp is also invaded, 
departs boldly from the hairy parts to the lower limits of the 
forehead, the lips, nose, cheeks, or chin, regions which are 
relatively spared by psoriasis. Finally, the two diseases, in 
doubtful cases, will generally be distinguished by carefullj' 
searching the entire surface of the body, upon some part of 
which, in psoriasis, there will usually be discovered a tell-tale 
patch of typical appearance. 

Scabies. — Scabies is really an artificial eczema induced by the 
incursions of the acarus scabiei, and its lesions are thus those 
of eczema. In scabies, however, the several papules, vesicles, 
and pustules are more likely to be coincident than successive, 
exhibiting thus the multiformity characteristic of the disorder 
when produced by .the parasite. The discovery of the presence 
of the latter, especially if there he a history of contagion and 
the localization of the disease in its sites of preference, will at 
once determine the diagnosis. These sites of preference are, in 
both sexes, the fingers, hands, wrists, and axillse; in the female, 
the breast and the nipple; in the male, the penis ; and in chil- 
dren, the buttocks. The presence of the acarian furrow, if the 
disease has existed for some time, and the appearance of little 
blackish dots or points upon or about the lesions, usually 
suffice to establish the real nature of the disease. 

Scarlatina. — This disease could only be confounded with 
certain of the varieties of eczema exhibiting an erythematous 
type In scarlet fever, however, the elevation of the tempera- 
ture, the appearance of the tongue and fauces, and frequently 
the history of contagion, serve to distinguish the disease. The 
peculiar " boiled lobster" appearance of the skin, and its sym- 
metrical distribution over the surface of the body, with gradual 
extension from the head and trunk to the lower extremities, 
are never seen in eczema. The finger-nail drawn across the 
skin of the patient affected with scarlet fever is usually followed 



122 DISEASES OF THE SKI X. 

by the ocenrrence of a whitish line corresponding with the im- 
pression made with the nail, which is highly characteristic of 
the eruption. Lastly, ii generalized eruption of eczema will 
never disappear with the rapidity of the scarlatinal rash. 

SEBORRHEA.- — Seborrhosa and eczema may coexist, either dis- 
ease preceding the other. Typical forms of each are readily 
distinguished. In eczema there is infiltration and much con- 
sequent itching; in seborrhea, neither. The scales of Bebor- 
rhcea are more voluminous, greasy, freely shed from the surface, 
and seated usually upon an integument of scarcely altered hue. 
In eczema the scales are dvy, scanty, and more firmly attached 
to a usually hyperssmic base. Seborrhcea of the hairy parts is 
generally symmetrically diffused ; eczema, though occurring 
with ill-defined contour, is rarely as symmetrical, usually more 
acute, and seldom followed by alopecia. Upon the non-hairy 
portions of the body the same distinctions can he to a great 
extent observed. The crusts of eczema removed from the face 
generally disclose beneath them an oozing surface, while the 
under surface of these crusts never exhibits the stalactite-like 
prolongations which pass from the under surface of the sebor- 
rheic crusts into the patulous orifices of the excretory ducts of 
the sebaceous glands. 

Sycosis. — Both the parasitic and the non-parasitic forms of 
sycosis are limited to the region of the beard, while eczema of 
the hairy portions of the face will usually be found to affect 
other regions. In eczema the itching is severe and the dis- 
charge characteristic, while in both forms of sycosis there is 
no oozing and the subjective symptoms are trivial. The dis- 
covery of the parasite in the root or shaft of the hair will at 
once distinguish parasitic forms of the disease. Eczema limited 
to the region of the beard is even rarer than the two varieties 
of sycosis. The circumscribed indurations and tuherculations 
of the affection produced by the trichophyton, as well as the 
loosening of the hairs in their follicles, constitute further dis- 
tinctive differences. 

Syphilis — There can be no question hut that several syphi- 
litic eruptions resemhle certain forms of eczema. In the erup- 
tions due to syphilis, however, there is usually a history of in- 
fection ; of involvement of the glands and mucous surfaces ; 
of ulceration and cicatrices in advanced periods; and, especi- 
ally in the case of infants with an eczema-like eruption, a his- 
tory of snuffles. It should always be remembered that the 
intense itching of eczema is characteristic of no one of the 
syphilides; and that the latter are remarkable for their ten- 
dency to occur with a circular or partially circular outline, and 
to be covered with bulky crusts of an offensive odor. A point 



ECZEMA. 123 

particularly worthy of note is suggested in the diagnosis of 
chronic eczematous affections. A syphilitic eruption limited 
for an equal period of time to one locality will often ulcerate 
or exhibit evidences of repair by scar tissue, no such lesions 
occurring in eczema. 

Tinea Circinata. — Tu ringworm there should be a history of 
contagion, microscopical discovery of the vegetable parasite, 
distinct contour of all separate patches, absence of marked sub- 
jective sensations and of discharge. These are not symptoms 
of eczema. In ringworm of the scalp the hairs are usually 
either brittle or actually broken at a short distance from the 
scalp; the scales are fine, dirty-white, and not torn from the 
surface by the finger-nails. In eczema the hairs are unaffected, 
and their extraction from the follicles is accompanied by pain. 

In ringworm of the body the patches are distinctly circular; 
more scaly or papular at periphery than centre; and, moreover, 
yield with exceeding promptness to the action of a parasiticide. 
Occurring about the thighs and ano-genital region, the disease 
may be complicated by eczema, but the characteristic "festoon- 
ing" of the advancing border of the patch downwards along 
the thigh, or upwards over the pubis, will suggest a microscopical 
examination of the scales scraped from the surface. 

Tinea Favosa. — The cup-shaped, friable, yellowish crusts of 
favus in the scalp might be mistaken for the crusts of eczema 
of the same part; but here the exudation is slight; there are 
no pustules of eczema, and hence no history of discharge. The 
odor, moreover, is characteristic. In case of uncertainty the 
microscope would indicate the parasitic nature of the disorder. 

Tinea Versicolor. — In this disease, also, the microscope will 
reveal, beneath the epidermal plates, the spores and filaments 
of the vegetation which produces the ailment. From eczema 
it is easily distinguished by the absence of infiltration and of 
any history of inflammation, by the very slight subjective sen- 
sation it produces ; by its peculiar fawn to chocolate-colored, 
slightly yellowish patches, with superficial furfuraceous des- 
quamation, limited otten to the anterior surface of the trunk, 
and readily removed by the action of a parasiticide. 



Treatment. — It is proposed to describe here the treatment of 
eczema in general, reserving the consideration of the treatment 
of the forms occurring in particular localities of the body to the 
pages which follow, and which are allotted especially to such 
local manifestations of the disease. 

In acute eczema, as well as in many of the chronic forms of 
the disease, the first and most important requisite is that which 



124 DISEASES OF THE SKIN. 

is tlif lumpiest, and, perhaps, for that reason most commonly 
overlooked. In order to attract to this point the attention 
which it deserves I will emphasize it by the aid of capitals as 

follows: — THE EXCLUSION OF ALL SOURCES OF IRRITATION. 

This completely secured, a large number of cases of the disease 
will proceed to a prompt recovery without any other treatment 
whatever. Failing this, acute become chronic phases of the 
disease; or. there is ;i history of exacerbation, recurrence, or 
development of the disorder in new, and, perhaps, distant por- 
tions of the body, from reflex irritation or augmentation of the 
sensitiveness of the skin to other sources of mischief. 

The exclusion of all sources of irritation necessitates, first, 
the withholding of all harmful internal medicaments. The 
number of patients presenting themselves for treatment of this 
disease, both in dispensaries, hospitals, and in private practice, 
who have aggravated their eczema by the medicaments they 
have swallowed, is incredibly large. Men and women, infants 
and adults, those who have been under the charge of physicians, 
and those who have purchased their drugs of the apothecary at 
the suggestion of the latter or of their friends, exhibit patches 
of acute or chronic eczema, intensely aggravated by the inju- 
dicious use of arsenic, iodide of potassium, bromide of potas- 
sium, Donovan's solution, and other harmful preparations con- 
tained in the various "blood-purifying" remedies sold in the 
shops. I strongly urge the practitioner who chances to read 
these lines, and whose patient comes to him after making trial 
of any such remedies, to carefully set aside the operation of 
such mischievous agents, and to watch the eruption carefully 
while their effect is vanishing. The result is often marvellous. 

The exclusion of all sources of irritation necessitates, in the 
second place, the avoidance of all injurious external contacts. 
Only gross ignorance or carelessness will overlook the fact that 
the inflamed skin, like the inflamed bone or the inflamed 
bladder, calls imperatively for rest. The prevalent idea is, how- 
ever, that the patient with an inflamed joint retires to h'is couch 
or bed, while the patient with an eczema, unless his disease is 
so formidable as to necessitate temporary withdrawal from the 
pursuits of business or pleasure, belongs always to the peripatetic 
class. He consults a physician, swallows some medicine, anoints 
his eczematous skin with a salve, and returns to the avocation 
where his complaint was begotten, just as the man with a gon- 
orrhoea will occasionally solace himself by embracing the source 
of his affliction. The baker goes to his baking; the seamstress 
still pushes her weary needle through the dyed fabrics which 
first injured her hands; the man with an eczema of the thigh 
walks the street with his trowser leg rubbing the affected sur- 
face ; the nursing mother, with an eczema of the infra-mammary 
region, still suffers the milk, chemically altered in the heat of 
the summer, to flow over the tender surface ot the breast; or, 



ECZEMA. 125 

in the ease of her infant affected with eczema, stuffs the folds of 
a coarse diaper, half laundried, or yet covered with the dejections 
from the bowel, between its thighs and over the anal region. 

Next is involved the exclusion of all topical irritants in the 
hands of either physician or patient, designed to relieve the dis- 
order, but having a precisely opposite effect. The number and 
variety of these articles are far from being commonly appreci- 
ated. Some are useful in advanced stages of the disorder, and 
harmful in its earlier periods. These are generally ordered by 
persons with a limited experience in diseases of the skin, and 
include a long list of stimulating and astringent ointments. 
Some are employed in sheer ignorance of their effects, as, for 
example, crude petroleum, strong acids and alkalies, nitrate of 
silver, turpentine, and concentrated solutions of corrosive subli- 
mate, intended to " burn out" the disease. 

Lastly, the exclusion of all sources of irritation necessitates 
saving the involved surface from the excoriations and other trau- 
matisms produced by scratching, rubbing, and excessive washing 
of the eczematous skin. In the case of adults some self-restraint 
is here needed; in the care of infants "this restraint may need to 
be enforced. 

This is the only proper treatment of eczema. That which is 
conducted without regard to this, is unworthy of the name. The 
methods of treatment, about to be described in detail, are to be 
regarded as entirely auxiliary to the measures and precautions 
suggested above. If the latter could be perfectly secured in 
every case, no other treatment would be required. If the patient 
protest that he must continue his avocation; the hands of the 
sugar-baker returning to their accustomed manipulations; the 
feet of the busy pedestrian to the frictions incident to his daily 
locomotion, then let both physician and patient distinctly under- 
stand the facts of the case. The former advises the speediest 
method of relief; and the latter elects a slower and more uncer- 
tain course. In doing this he should be made to understand 
that the responsibility is, to that extent, to be borne by himself. 
What competent surgeon consents to be responsible for that 
fracture in which the extremities of the bone are daily subjected 
to movement on the part of the patient I 

The great importance of rest and freedom from irritation of 
all sorts in eczema is well illustrated by two classes of cases. 
There is, first, the newly-born infant, whose sensitive skin 
responds early to its first harsh acquaintance with the outer 
world, by an explosion of eczema. But it is a fact of singular 
importance that no child is born into the world eczematous. 
If the nervous system were responsible for eczema, such a result 
might occur, for that system is not only capable in intra-uterine 
life of producing club-foot and other deformities, but also of in- 
fluencing skin disorders. 1 have reported a case of pigmentary 
moles at birth where the lesions were distributed exactly in the 



126 DISEASES OF. THE SKIN. 

situation of herpes zoster of the trunk, along the lines of the 
intercostal nerves. If the blood were responsible for eczema. 
the foetus surely might display its lesions, as it does those of 
syphilis. Animal poisons, as those of variola and scarlatina, do 
not spare the unborn child. Nor is it exempt from certain dis- 
eases of the integument which are generally regarded as due 
solely to tissue changes, since new-horn infants are occasionally 
seen affected with ichthyosis or sclerema neonatorum. 

Why is the tender skin of the foetus saved from every form 
of eczema, and the tender skin of the infant, accessible to all of 
its various approaches? Will it he responded that the child 
has begun to respire and digest for itself; that it has become 
suddenly strumous, dartrous, rheumic, arthritic, gouty, or her- 
petic; that its standard of health is impaired; that it is sutfer- 
ing from assimilative, nutritive, or nervous debility, or from 
any one of the other numberless perturbations to which eczema 
has been ascribed? For him who can divest himself of all pre- 
judice, there can be but a single answer to the question. The 
difference between the child unborn and the child born is, as 
regards eczema, a difference solely of skin protection and skin 
exposure. The former enjoys what Dr. White has aptly termed 
a "prolonged, placid, subaqueous life." Anointed with un- 
guent and immersed in its water-bath of grateful temperature, 
its skin cannot he fretted to produce an eczema. The latter, 
abruptly and often rudely brought into contact with the outer 
world, may speedily exhibit the most formidable symptoms of 
the disease. 

The second class of cases to which I refer, exhibit the reverse 
of this picture, and are best observed in hospital practice. 
Attacked with such severe symptoms of the disease as to justify 
admission to these Charities, eczematous patients, usual]}' im- 
poverished in their resources and often injured by exposure 
during severe bodily toil, rarely fail to improve greatly daring 
the course of a few days, when no treatment of an active sort 
has been adopted. In the larger number of cases, while waiting 
to study the evolution of the disease, I have been limited to the 
observation of its involution. The mere rest in bed in a recum- 
bent position, with a proper regulation of the diet and exclu- 
sion of all sources of irritation, has here been sufficient to secure 
relief. 

If any apology is needed tor the space devoted to this part of 
an exceedingly interesting subject, it must be based upon the 
great frequency of the disease; the wide diffusion of erroneous 
doctrines respecting its nature and the method of its manage- 
ment; and the mischief resulting from the too common aggra- 
vation of the disease in its earliest manifestations. 



ECZEMA. 127 

The most soothing application which can be applied to the 
skin affected with acute eczema are, in various proportions and 
combinations, water, oil, dusting powders, and occasionally oint- 
ments. These will be separately considered, but two important 
circumstances must be remembered in their employment; first, 
that an article which will be grateful to the skin of one patient 
may prove irritating to another, the two being to all appearance 
similarly affected; second, that where the surface is broken, 
from rupture of vesicles, excoriations, abrasions or fissures, an 
applied fluid should be of greater specific gravity than the serum 
which is exuded, since otherwise endosmosis and exosmosis will 
occur, and the surface in consequence become more tumid and 
painful. 

Olive or other bland oils may be poured over the surface, 
applied upon folded pieces of lint, or used by inunction. Even 
these substances are at times, however, the sources of irritation. 
They are made more soothing by combination with an equal 
part of liquor calcis, as in the Carron oil, constituted of equal 
parts of linseed oil and lime-water. For the linseed oil it is 
frequently advantageous to substitute cod-liver oil, palm oil, oil 
of sweet almonds, neat's foot oil, olive oil, or lard oil, flavored 
very slightly with bergamot or lavender to correct the disagree- 
able odor. In combination with equal parts of lime-water, one 
of these may be gently smeared over the surface ; while a piece 
of lint, saturated with the same preparation, is also applied. In 
many cases the value of this dressing is greatly enhanced by sur- 
rounding the whole with oiled silk, or other impermeable tissue. 

The dusting-powders, described in the chapters on general 
therapeutics and the erythemata, are available in many cases 
where the surface of the skin is, or is not, broken. These may 
be composed of lycopodium, magnesium, bismuth, talc, the oxide 
of zinc and camphor, when an anti-pruritic effect is desired, in 
combination with finely powdered starch. The Anderson pow- 
der, the formula for which has been already given, is a useful 
combination of camphor, starch, and zinc. In their preparation 
it is of prime importance that they be made perfectly impal- 
pable by sifting them carefully through silk bolting-cloth, as 
they are sources of irritation when they contain grain-like par- 
ticles of untriturated material. The finely bolted " Oswego 
gloss starch," "corn starch farina," and rice flour, sold by the 
grocers, either singly or in combination with the other articles 
named, are generally accessible and prepared at hand. It will 
often be of advantage, where exercise in the day is not to be 
prohibited, to employ one of the oily preparations during the 
night, which can ue removed in the morning by a weak, alka- 
line bath, containing borax, or the sodic bicarbonate, while the 
patient employs a dusting-powder in the daytime. This can be 
freely dusted over the surface, as also over the soft lint in con- 
tact with the eczematous skin ; the stocking, gloves, or sus- 



1 28 DISEASES OF THE SKIN. 

pensory -bag being also well protected by the powder on its inner 
face. 

Water is of value in many cases when properly applied. Ex- 
ive washing of the eczematous surface is not only disagree- 
able to the patient, but irritating to the inflamed skin. Hot 
water, applied either as a lotion, bath, fomentation, or by spong- 
ing, is frequently grateful, and alleviates tbe itching. If em- 
ployed at all, its use should be immediately followed, as soon as 
the part is carefully dried, by the other medicament selected for 
topical application, such as an oily or fatty substance, or a dust- 
ing-powder. 

Cold water is of service only when it can be continuously 
applied, as its intermittent employment is followed by a vivid 
reaction in the skin capillaries, whereby the itching is greatly 
increased. Thus are explained many of tbe nocturnal exacerba- 
tions of tbe disease, notably those occurring soon after the 
patient retires to his or her bed. A cold bathing of the part 
before retiring has been followed by a temporary calmative 
effect, the blood being driven from the capillaries by the con- 
traction of the tissues. The return of the circulating fluid in 
excess has then been aided by the warmth of the bed and the 
bed clothing. The continuous application of cool or cold water 
requires a constant supply of the fluid from a reservoir of fixed 
temperature, and the exposure to the air of the part to which 
the dressing is applied. Thus evaporation is not checked ; and 
what is intended to be a continuous cold dressing is not trans- 
formed into a hot fomentation. 

Such hot fomentations are, however, frequently grateful to 
the patient's skin, and at times fulfil a good purpose. They are 
applied by dipping soft pieces of cloth in hot water, applying 
them neatly over the affected surface, and covering them with 
oiled silk, rubber cloth, or the "protective material" employed 
in antiseptic surgical dressings. Poultices of flaxseed, elm bark, 
or other bland materials operate in a similar manner, but are 
chiefly useful in softening crusts, or other morbid concretions 
upon the surface. When too continuously or too frequently 
employed, they are productive of harm in their macerating and 
relaxing effect upon the skin, whereby its natural tonicity and 
instinct of self-repair (if such a term be permitted), are to a 
degree obtunded. They are hence but little used in eczema. 
The combined employment of water and fatty substances is an 
exceedingly valuable method of soothing the eczematous skin, 
but, with the means accessible in the private practice of many 
physicians, can rarely be secured. It certainly approximates 
most closely the sebaceous envelope and warm-water bath of 
foetal life. The eczematous skin is first anointed gently with a 
bland unguent, such as mutton tallow, suet, cold cream, or vase- 
line, and is then immersed in a bath of water kept continuously 
at the temperature of the blood. In the case of the lower ex- 



ECZEMA. 129 

tremities this is accomplished without great difficulty. Less 
perfect than this is the anointing of the surface and the sub- 
sequent application of a warm fomentation, by strips of soft 
lint dipped in the water, superimposed with neatness, and sub- 
sequently covered with the protective gauze. Imbibition of 
fluids by the skin is prevented by its careful anointing; and, 
when immersed in the water, the pressure is botli uniform and 
gentle. 1 

Medicated water in baths and lotions plays an important part 
in the treatment of acute eczema. The liquor calcis with calo- 
mel, half a drachm (2.), and pure glycerine half an ounce (16.) to 
the pint (512.); the lead and opium wash; carbolic acid one 
drachm (1.), and glycerine two drachms (8.) to one pint (512.) 
of camphor water; a decoction of opium, made by boiling five 
to ten grains (0.33-0.66) of powdered opium in a pint (512.) of 
water, which is strained and rendered demulcent with mucilage; 
these and similar lotions, the ingredients of which are changed 
to suit the indications of each case, often serve to alleviate the 
itching, and in that proportion to diminish the intensity of the 
disease. Dr. White, of Boston, after bathing the parts for sev- 
eral minutes with the lotio nigra, dilute or in full strength, 
gently smears the surface with a small quantity of the oxide of 
zinc ointment. Dr. Taylor, of New York, has suggested the 
following, which I have used with advantage in many cases: — 

I£. Liq. plumbi subacetat. ^ij ; 8 

Opii tinct. §ij ; 64 

Camphorae tinct. §j ; 33j 

Glycerinse §ij ; 64! M. 

Sig. To be mixed with a quart of water and applied on lint. 

To this solution, a greater astringent effect can be given by 
the addition of the sulmitrate of bismuth or oxide of zinc, half 
an ounce (16.) of either to the pint (512.) of the lotion. 

Dr. Duhring, of Philadelphia, has greatly popularized the use 
of the fluid extract of grindelia robusta in the proportion of one 
to two drachms (4.-8.) to four to eight ounces (130.-250.) of 
water, as a lotion in eczema. I can say from experience, that 
many patients will in this way secure relief which they cannot 
otherwise obtain. 

Other useful lotions contain finely levigated calamine, one to 
two ounces (30.-60.) to the pint of rose-water, with a small quan- 
tity of glycerine, and, if the itching be severe, in addition half a 

1 A convenient method of making the applications described above, is by the 
aid of spongio-piline. The eczemalous surface is first anointed with a bland, 
neutral unguent, and then covered with a piece of spongio-piline, cut to the 
required size, sewn to a somewhat larger sheet of oiled silk or Lister protective, 
so that the edges may project on every side. The whole is retained in place 
by a flannel or muslin bandage, to which the edges of the impermeable material 
are attached by stitches. The spongio-piline is moistened with pure or medi- 
cated water, as desired, of a temperature nearly that of the stomach, and may 
be re-moistened from time to time. 

9 



130 DISEASES OF THK SKIN'. 

drachm (2.) to one drachm (4.) of dilute hydrocyanic a<-id. 
Boracic acid, one to two drachms (4.-8.) to the pint of an opiated 
wash ; and borax or the bicarbonate of sodium in the same pro- 
portion, containing besides an equal proportion of alcohol, spirits 
of camphor, or chloric ether, is also available. With any of 
these it is proper to frequently moisten the soft lint upon which 
they arc applied, and this after ablution with hot, pure or 
slightly medicated, water, for the purpose of relieving the itching. 

I have used with marked success in the early treatment of 
acute eczema, a fluid preparation whose composition is unknown 
to me, and whose employment in such cases was first suggested 
to me by Dr. II. A. Johnson, of Chicago. It is sold by the gro- 
cers under the proprietary title of "coaline," for laundry pur- 
poses. It is evidently one of the petroleum products, but is 
alkaline, freely miscible with water in all proportions, and, in 
an undiluted state, can be used as a lotion without irritative 
effects. It is non inflammable, though a very small quantity of 
a clear inflammable fluid can be decanted from the neck of a jar 
containing several gallons. It saponifies with oil, and in the 
proportion of eight ounces (250.) of this fluid to two (64.) of lin- 
seed oil and half an ounce (16.) of glycerine, it supplies a bland 
feebly alkaline and slightly saponified mixture, which is exceed- 
ingly grateful to the eczematous surface. 

From what has preceded, it will be clear that, the chief end in 
the treatment of an acute eczema, is the relief of the subjective 
sensation of itching, and the exclusion of all irritants, the two 
being practicall}* one. That which is not grateful to the skin 
of a patient thus complaining, had better be, for the time at 
least, abandoned. So great is the difference between different pa- 
tients as to the toleration by the skin of various topical remedies, 
that it is well, as a rule, at the time of the first consultation, to 
order an alternative treatment, the one to be immediately sub- 
stituted for the other, if such necessity arise. Especially is this 
true in cases where the epidermis is wounded, and where the 
patient can sometimes with comfort to himself exchange a dust- 
ing powder for a lead wash or a weak carbolized oil and lime- 
water lotion, while his eczema is tormenting him in different 
decrees at different hours of the day. 

The necessity for this relief is so imperious that at times it 
overshadows all other symptoms of the disease. He who has 
never studied the case of a man or woman possessed with a furious 
impulse to relieve an intense eczematous pruritus, has not yet 
completed an education in medicine. The fury, for such it really 
is. has been likened to the sexual orgasm, with which it is un- 
doubtedly allied, as the two are not rarely coincident when 
there is severe anal or genital itching. The features of the pa- 
tient are drawn; he is but half conscious of his ejaculations and 
surroundings; with his nails or other object which he employs 
he attacks the too vulnerable skin with an incalculable savagery. 



ECZEMA. 131 

In these exaggerated paroxysms, nothing but blood will suffice 
for his relief. Not till the torn and wounded surface oozes with 
red drops at every point does he emit the sighs which indicate 
that his desire is satisfied. I have seen men and women forcibly 
withheld from doing themselves this severe damage, in whom 
the muscular spasm, facial expression, and movements of the body, 
were scareel}' distinguishable from the symptoms of an epileptic 
seizure. This brief outline of a picture familiar to those who 
have had experience of exaggerated cases, will serve to enforce 
the need of the utmost care in selecting a topical remedy in acute 
eczema, the greatest gentleness in its application, and the nicest 
provision for the special needs of each individual patient. 

In proportion as the disease progresses to a subacute or chronic 
stage, the various topical medicaments employed may be changed 
in character so as to produce an astringent or stimulating effect 
upon the part. The utmost skill and prudence, however, are 
needed at this juncture; and when uncertain as to the proper 
course, it is well to continue the dusting powder, oleated lotion 
of lime-w T ater, or whatever other article may be externally em- 
ployed. For it is at this time that the disorder is readily 
awakened to renewed activity, a turn of affairs which is especially 
annoying to the patient, and particularly so to the practitioner 
if there be a suspicion (truth to say, often too well founded) that 
the aggravation has been due to the treatment. It goes without 
saying, that the routine practice in eczema has long been to order 
an application of the benzoated oxide of zinc ointment, irrespec- 
tive of the particular features of the malady in any individual 
case. Now I know of no greater error which in this special di- 
rection can be committed. The acutely inflamed skin will rarely 
tolerate the most perfectly medicated ointment; and as this acute- 
ness subsides, such tolerance is first to be carefully tested, as, for 
example, by applying a weak ointment to a part only of the 
affected surface. The term, rarely, is, however, here used ad- 
visedly. With that singular capriciousness which distinguishes 
the eczematous skin of different individuals, the zinc ointment 
occasionally affords very great relief in the severest forms of 
acute vesicular disease. 

In the application of such ointments it should be remembered 
first, that they must be sweet and freshly and carefully prepared ; 
second, that they can be advantageously applied by gently rub- 
bing them into the part by the tip of the finger, after which soft 
lint in strips, spread with the same material, may be neatly 
superimposed ; third, that an ointment, if selected, need not 
necessaril}' be applied to every part of the inflamed skin, since a 
little pad or circlet of lint may be applied only to an oozing or 
pustular patch ; lastly, that the debris of one dressing should 
be carefully removed before another application is made. Strata 
of any ointment, the older next the skin possibly rancid and 
having imprisoned beneath them pus or other products of the 
disease, are positive sources of harm. 



132 DISEASES OF THE SKIN. 

Appended are a few formulae for ointments useful in this 
Stage of the disease : — 

R. Zinci oxitl. 3s s ; 2 

Hydrarg. amnion. -chloral, grs. V~9s8 ; 33-. 66 

Camphor, pulv. 3 ss_ 5.i i 2-4 

Qngl aq. ros. gj ; 32 M. 

For the oxide of zinc may be substituted the suhnitrate or 
the subcarbonate of bismuth, or from two to four grains (.133- 
.266) of the red oxide of mercury, or from four to ten grains 
(.266-.666) of the mild chloride. The cold cream makes an 
agreeable basis for these ointments, though lard, simple cerate, 
vaseline, or equal parts of vaseline ami the other preparations 
answer a good purpose. The cerates are made sufficiently soft 
for gentle manipulation by adding a drachm (4.) or two of 
glycerine to each ounce (32.) of ointment, and may be flavored 
with lavender, rosemary or bergamot to suit the taste. 

The oleate of bismuth or zinc is prepared by rubbing up one 
drachm (4.) of the oxide of either metal with eight (32.) 
drachms of oleic acid, which is then allowed to stand for two 
hours. It is afterward heated in a water bath, when ten 
drachms (40.) of vaseline and. three (12.) of wax are dissolved in 
it, the whole to be stirred until cold. It is especially useful 
in the papular forms of eczema. 

The well-known diachylon ointment of Hebra occupies a. fore- 
most place in all lists of articles useful at this period of the dis- 
ease and even later. It is prepared as follows: — 

Fifteen ounces of the best olive oil are added to two pounds 
of water, and heated to boiling in the water bath. Three 
ounces and six drachms of an equally good article of litharge 
are dusted over the fluid in ebullition, which is constantly 
stirred throughout, in order to prevent the formation of fatty 
acids. During the cooking, water is occasionally added as re- 
quired. The stirring is to be continued till the ointment is 
quite cold. 

Duhring has lately modified this ointment as follows: — 

One part of freshly precipitated (from acetate of lead) pure 
white hydro-oxide of lead is rubbed down with two parts of 
water, and well mixed with six parts of the best Lucca olive 
oil. Stir the mixture for about two hours over a hot-water 
bath near the boiling point, and then cool with constant stirring 
until the proper consistence is obtained, and while the mass is 
cooling add one drachm of the oil of lavender to each half 
pound of ointment. The preparation, according to Eisner, a 
Philadelphia chemist, is said to contain the oleo-stearate of 
lead. 

When properly prepared this ointment is perfectly homo- 
geneous, of a light yellowish color, ami of the consistency of 
butter. It has been modified by Piffard, and after him by 
Kaposi, by combining equal parts of lead plaster and vaseline, 



ECZEMA. 133 

and in this form exclusively has been employed by me since 
the modification was first suggested. It is commonly flavored 
with the oil of lavender. It is technically known as the un- 
guentum diachyli albi, of Hebra. 1 

This valuable ointment, though useful often in full strength 
and even to the exclusion of all others, is yet with such others 
often combined with manifest advantage. Thus a drachm or 
two (4.-8.) of it may be added to the ounce (32.) of lard, cold 
cream, or cerate, with or without the addition of another 
drachm or two (4.-8.) of the oxide of zinc ointment, or even 
one of the tarry preparations to be mentioned later. 

In chronic eczema it is necessary at first to remove from the sur- 
face all dried products of the inflammatory process which usually 
remain upon the surface, such as crusts, scales, and masses of 
effete epidermis. For this purpose oil is to be freely used, and 
care should be taken that it is rubbed gently into every part 
of the affected patch. A species of oil poultice may also be 
applied by saturating pieces of flannel or layers of antiseptic 
cotton with either cod-liver or olive oil, and covering these 
with protective silk gauze and a light bandage. As soon as 
the inflammatory products are softened they are removed by 
washing with soap and water, using for this purpose either the 
ordinary toilet soap, or, where the skin will permit, the spirit 
of green soap, described in the chapter on general therapeutics. 
The crusts and scales once removed, subsequent topical applica- 
tion may be made as required in each case. 

The acuteness of the disease having fairly subsided, not only 
as regards the question of time but more especially as concerns 
the question of what the skin will tolerate, the tarry and allied 
preparations become for the first time worthy of consideration. 
Valuable indeed when such toleration has become experiment- 
ally established, they are sources of positive injury when the 
acuteness of the inflammatory process has not completely sub- 
sided. 

The articles of this class most commonly employed are pix 
liquida, oleum cadinum, oleum betullre albse (or the oil of white 
birch), and terebinthina Canadensis (or the balsam of fir). The 
oil of cade as found in most of the shops, is inferior in purity to 
the oil of white birch, which is certainly the more elegant of 
the two articles. They are best applied in the form of oint- 
ments, but are occasionally painted over the surface with a 
camel's-hair brush in a liquid state. From one-half to two 
drachms (2.-8.) of the tar, in combination with a suitable quan- 
tity of the subcarbonate of potash, are sufficient to add to a single 

1 Messrs. Thomas Whitfield & Co., and Buck & Rayner, of this city, have 
supplied me with excellent samples of this ointment, which I have compared 
with selected preparations from the best known manufacturers of it in this 
country and abroad. The ointment, as it has been supplied to me by these 
gentlemen, is equal in value to any I have found. 



134 DISEASES OF THE SKIN. 

ounce (32.) of ointment, the proportions suggested being varied 
to suit tlie requirements of each case. In attempting to meet 
such requirements, it may occasionally l>e found useful to com- 
bine with these ointments the oxide of zinc, the mercurial com- 
pounds, <>r thi' diachylon ointment of Hebra, already described. 
The following formulae are illustrations merely of the manner 
of compounding these articles: — 



. 01. betull. alb. (vel cadini) 


3ss-3jss ; 


i-fi 


Potass, subcarbouat. 


9J-38S ; 


.66-2 


Unguent aq. res. 


§j; 


32 


. et ft. ungt. 







f.3j-ij ; 


32-64 


fSJ ss 'U ; 

f§viij ; 

f.-ss ; 


48-9(5 

32 

256 

2 



Fertile potassic Bubcarbonate one-half to one drachm (2.-4.) 
of the zinc oxide may he substituted, or from two to four grains 
(.133-.266) of the red oxide of mercury, or yet half a scruple 
(.0(30) of the mild chloride. The vehicle also of such ointments 
may he vaseline, simple cerate, or half an ounce ^16.) of either in 
combination with an equal quantity of diachylon ointment. 

Of the fluid preparations may he mentioned, alcoholic solu- 
tions of tar, half an ounce (16.) of the latter to the pint (512.) of 
alcohol; and, in cases where the detersive action of soap is also 
needed, the sapo viridis may he added as follows: — 

\i. Picis liquids 

Sapon. virid. 

Glycerin. 

Spts. vin. rectif. 

01. rosraarin. f.^ss ; 2i M. 

Sig. To be rubbed gently into tlie skin with a flannel rag. 

Dr. Bulkley, of Xew York, has devised an alkaline solution 
of tar and caustic potassa, which is especially serviceable, as it is 
miscible with water in all proportions. It is constituted as 

follows: — 

B Picis liquid a? f§ij ; 64! 

Potassae causticre §j ; 32 

Aq. destillat =v ; 160 M. 

Dissolve the potash in the water, and add slowly to the tar in a mortar with 
friction 

Big. " Liquor picis alkalinus." To be used diluted as a lotion 

A drachm (4.) or more of this solution may be added to a pint 
(512.) of water; and, as an ointment, the same quantity to the 
ounce (32.) of cold cream or vaseline. It should be remembered, 
however, that the caustic alkali renders it exceedingly irritating 
to a sensitive skin, and it should he employed with caution upon 
any untested surface. 

Hebra disclaimed any special value for sulphur in eczemas 
uncomplicated by the acarus seabiei, hut in Wilkinson's and 
other ointments, it has certainly served a good purpose. The 
following formula supplies an ointment much less severe and 
offensive to the nostrils than Wilkinson's, and which I can cer- 
tainly recommend for its practical efficacy in chronic eczema: — 







ECZEMA. 






R 


Picis liquid. 




§iv; 


130 




Adipis 




?j; 


30 




01 olivce 




I ss ; 


16 


Misce et adde 










Terebinth. Canadeus 


} 








Sulphur, flor 


aa §j ; 


30 


Si 


g To be applied three 


times daily with a sr 


ft brush. 



135 



To this may be added the green soap, if a stronger effect is 
desired. 

Olive or cod-liver oil may be rubbed into the eczematous skin, 
after combination with equal parts of one of the tarry prepara- 
tions; and carbolic acid in lotion and ointment with the balsam 
of Peru, though less effective, answers well in many cases. 

Whatever article be selected, it should be thoroughly rubbed 
into the affected surface several times in the day, after a small 
portion of the skin has been attacked to test its susceptibility. 
IShould the redness, itching, secretion and infiltration be aggra- 
vated by such application, it will be needful, for a time at least, 
to exchange the local treatment for one less stimulating. Should, 
however, the tarry or other similar application be well borne, it 
should be reapplied till it is no longer washed away by the ooze 
from the skin. Sometimes it is well to permit the former to 
accumulate till it is naturally shed from the surface by exfolia- 
tion, a course which will be indicated by the absence of all local 
distress. The new epidermis, which forms beneath such a coat- 
ing, should be for a time protected by a dusting powder. Occa- 
sioning no further subjective sensation, it speedily loses its red- 
ness, and assumes a normal appearance. 

In other cases, indicated by local distress and exaggerated 
secretion, it will be found useful to remove the tarry application 
completely. After saturating it for a few hours with oil, the 
surface may be cleansed with a weak alkaline lotion, and the 
tar compound then reapplied to the oozing skin with flannel or 
camel's-hair brush, according as recourse is had to an ointment 
or solution. 

Hebra used to employ in chronic eczema of obstinate kinds a 
remedy which he claimed to be his ultimata refugium, and which 
"cures every case without exception," the concentrated liquor 
potassse. The objections to its use are, however, grave. It pro- 
duces severe pain, and in inexperienced hands it is dangerous. 
As a consequence, this distinguished dermatologist adopted two 
methods which he regarded as partial substitutes for it. The 
first was the inunction of the body thoroughly and firmly with 
green soap, which was not removed by washing, but left in con- 
tact with the skin for several days, while the patient was wrapped 
in blankets. The second was his well-known method of treating 
more circumscribed patches of chronic eczema with soap washing 
and ointment, the process being described below in nearly his 
own language: — ■ 

A piece of green soap as big as a walnut is spread upon a flannel 



136 DISEASES OF THK SKIN. 

rag, and rubbed into the eczematous part for several minutes, 
pressing firmly the while, and from time to time dipping it into 
water in order to produce a better lather. The part is then 
washed free of suds with water, carefully dried, and the oil or 

ointment selected for topical use immediately applied on strips 
of muslin. These are neatly bandaged to the part. The soap 
must be rubbed in at least twice every day so lontr as an}' exco- 
riated points appear after its application. Soap rubbed into the 
healthy skin will not be followed by such effects; the part feeling 
clean, smooth and comfortable after it has been washed off with 
water. The contrast this offers to the eczematous parts is very 
Striking, the latter presenting numerous intensely red, raw and 
moist spots These are all caused by the action of the soap in 
softening and destroying the layer of cuticle which was before 
undermined by the eczematous fluid so as to form coverings for 
vesicles. Each, therefore, represents the floor of a vesicle, the 
roof being removed. The appearance of these red, shining, moist 
points after the first inunction suggests to the inexperienced eye, 
that the malady has been aggravated ; but they become fewer 
in number after each application, and finally entirely disappear, 
the eczematous surface being then no more affected by the soft 
soap than is the surrounding healthy skin. 

Frazer 1 speaks highly of the application of iodoform to ecze- 
matous patches. It is employed in the form of an ointment, 
containing from ten to thirty grains of powdered iodoform to 
the ounce of cerate. 

Other stimulating articles have been found useful in the treat- 
ment of eczema. Among these may be named cantharides, em- 
ployed as a blister, the nitrate of silver in crayon or solution, 
and iodine in combination with carbolic acid. The following 
formula should furnish a clear vinous-red fluid, which may be 
applied pure or in dilution : — 



R. Iodin tinct. 3ss ; 2 

4 



Iodin tinct. 


3ss; 


Acid carbolic, (cryst.) 


sj; 


Glycerin., 




Alcoholis. 


aa 5'j ; 


Aq. dcsiillat. 


a.lt'sj; 



M. 



Iodized solution of carbolic acid. 



In cases where there is considerable pruritus, especially in 
obstinate patches of papular eczema, the iodized phenol of .Bel- 
lamy may be substituted for this. The formula is: — 

R. Iodinii cryst., ) ,, N 

Acid, carbol.; \ ** & <*■) 

Combine will) gentle beat and ndd an equal part of glycerine. 
Sig. Iodized phenol ; to be applied twice daily with a glass rod. 

Mr. Balmanno Squire, of London, has suggested a substitute 
for the diachylon ointment, in the glycerole of the subacetate 

' British Medical Journal, July 16, 1881, p 80. 



ECZEMA. 137 

of lead. It is certainly a valuable preparation, and I hnve em- 
ployed it with advantage in many cases, but am unwilling to 
admit its superiority over the other ointment named. The 
u stock" is prepared as follows: Take five parts of the acetate 
of lead, three and one half of litharge, and twenty of glycerine, 
heat for half an hour in a boiling glycerine bath, constantly 
stirring, and filter in a gas-oven or other kind of heated apart- 
ment. From one-half a drachm to two drachms (2.-8.) of this 
stock, added to the ounce (32.) of pure glycerine, are sufficiently 
strong for application to the oozing surfaces of eczema rubrum. 
Lassar? recommends that the part affected should be at first 
well soaked with antiseptic oil, of which a considerable quan- 
tity is absorbed by the skin. A muslin bandage, soaked in oil, 
is then applied and covered with oil silk. The oil may be ren- 
dered antiseptic by the addition of one to two per cent, of car- 
bolic or salicylic acid, or one and one-half per cent, of thymol. 
Sometimes the carbolic acid can only be borne for a short time, 
as it will of itself produce eczema. .Rape-seed oil may be used 
in place of the more expensive olive oil ; but drying oils, such 
as linseed oil, are to be avoided, as they may cause inflamma- 
tion. In chronic eczema, especially in infants, and in eczema 
of the face, he recommends an ointment. The formula for an 
ointment which cannot be rubbed off during sleep in eczema of 
the face is: — 

Salicylic acid 

Oxide of zinc 

Starch 

Vaseline gij ; 50 Mix. 

Wyndham Cottle 2 has employed chaulmoogra oil, or gyno- 
cardic acid, in a large number of cases of eczema occurring in 
persons with delicate skins, and over such exposed surfaces as 
the face, hands, and arms. In both acute and chronic forms he 
has employed these substances in the form of ointment, in the 
strength of from fifteen to twenty-five grains (1.-1.5) to the ounce 
(32.) of vaseline. The ointment is applied several times in the 
day, and, if possible, kept in contact with the part on rags over 
which it has been spread. 

Other mercurial preparations than those named above have 
long been in favor for application to localized patches of the 
disease. Among these may be named corrosive sublimate, the 
ammonio chloride, the iodide and biniodide, the two oxides, 
and the nitrate. 

Calomel, which is useful in the strength of a scruple to a 
drachm (1.-4.) to the ounce (32.) of ointment, can be often ad- 
vantageously employed also as a powder in full strength or 
diluted with bismuth or starch. In localized patches of papular 

1 Annal. de Derm, et de Syph., Sept., 1881. 

2 British Medical Journal, June 25, 1881. 



3vj ; 


25 


3vj; 


25 


§U; 


50 



138 DISEASES OF THE SKIN'. 

eczema, where such a dressing can l>e tolerated, I have fre- 
quently found marked results follow this dry dusting of calomel 
over the part, followed by alternate superposition of neatly ad- 
justed strips of Maw's surgeon's plaster; the whole kept in situ 
by means of a neat bandage. If the itching is alleviated by 
Buch a dressing, it can he reapplied for a week as soon as it is 
loosened, when the redness ami infiltration will be found greatly 
reduced. 

Other surgical appliances used in the local treatment of eczema 
are Martin's solid rubber bandage, Fox's tubular bandage of 
rubber, and other dressings composed of starch, gutta perch a, 
and plaster of Paris, intended to support the extremities when 
the integument is weakened. None of these, in my experience, 
are equal to rest in the recumbent posture. The most useful 
purpose subserved by rubber in the treatment of cutaneous affec- 
tions is as an impermeable outer dressing for watery and oily 
applications. Here the mackintosh and silk protective of the 
Lister dressing answer all the indications. 

Constitutional Treatment of Eczema. — If the remarks which 
have preceded are justified by the clinical and pathological his- 
tory of eczema, it follows that there is no constitutional treat- 
ment of the disease, save that which excludes all sources of 
irritation, a point to which attention has been already called. 
Once fully persuaded of this important truth, the physician 
should be capable of managing the complaint without mental 
bias in the direction of futile experimentation with drugs. 

The treatment of the patient, however, may be in one sense 
regarded as the treatment of his disease, though I am thor- 
oughly persuaded that a very large number of eczematous pa- 
tients are, except as regards the skin, in conditions of health. 
Constitutional treatment, to meet any general conditions of ill- 
health, should be such as is made familiar to the physician in 
his experience as a general practitioner of medicine. It goes 
without saying, that the anaemic patient will be benefited by 
the chalybeates ; the dyspeptic, by the remedies calculated to 
relieve such a condition ; the rheumatic, by the lithium salts, 
the diuretics, and alkalies; the cachectic and strumous, by cod- 
liver oil, malt, and similar preparations. 

But this is merely the enumeration of a few disorders in the 
long list which may coexist with eczema. Many male patients 
with a gleet have an eczema of the thigh, kept up by the dis- 
charged secretion, which calls for treatment calculated in a very 
indirect manner to relieve also the cutaneous disorder. The 
same ma}' be said of an otitis externa with a purulent discharge, 
and of other local and constitutional ailments which the skilled 
physician should be competent to recognize and treat. Be it 
clearly understood the while, that all such treatment will not 
relieve an eczema. It simply places the patient in the most 
favorable condition for getting rid of local trouble. For several 



ECZEMA. 139 

years past I have had the opportunity of observing a large num- 
ber of eczematous patients, of every social class, treated by 
internal medication of the character approved by those who 
still cling to a belief in the constitutional nature of the disease ; 
and the statements here made are based upon a conscientious 
study of this experience and of the results of personal experi- 
ments in the same direction. He who desires to build solidly 
will not lay his corner-stone upon the shifting sands, where so 
many have been disappointed before him. 

Bearing in mind the fact that an eczema will occasionally 
vanish under even the worst mismanagement, the value of 
arsenic administered internally for its relief should be duly esti- 
mated. It is an uncertain remedy in all cutaneous diseases; it 
is, if possible, more uncertain in eczema ; and has unquestionably 
aggravated more cases than it has relieved. Its value in chronic 
and persistent forms of the disease is attested by men of distin- 
guished reputation ; and upon such authority it may be conceded 
a position among the internal remedies for the malady, of pos- 
sible value. It has been my ill-fortune to observe so many ob- 
stinate forms of squamous and papular eczema aggravated by 
its employment, that I should consider an acquaintance with 
a dozen patients relieved by its use in a single year, a circum- 
stance suggestive of as much curiosity as congratulation. It is 
indeed not as remarkable that a few patients annually recover 
under its administration, as that more do not attain the same 
fortunate end. For it is the favorite dernier ressort, in chronic 
scaling diseases of the skin, with physicians of every grade of 
professional proficiency; and, having in view the large per cent- 
age of eczematous cases with which they are confronted, it is a 
curiously suggestive fact that the position of arsenic in eczema 
is yet open to discussion. If arsenic, which certainly does pos- 
sess an influence over the skin, cannot to-day be demonstrated 
to have any therapeutic value in the large proportion of all cases 
of eczema, what can be said of the host of other drugs too com- 
monly employed for a similar purpose, which are inferior to 
arsenic in their cutaneous effects ? Sunlight, fresh air, a properly 
selected diet, suitable clothing, and due regime as to pleasure 
and business; these must be, for many patients, controlled by 
the physician. They do not cure eczema. They may do much 
to aid in its management; they may do more, if neglected, to 
furnish sources of its aggravation. 

Prognosis. — The greatest uncertainty attends the prognosis 
of eczema, so far as regards the duration of the disease and the 
probability of the recurrence of a relapse. With respect to the 
questions most frequently asked, those relating to contagion, 
hereditability, and persistent lesion relics, naturally a favorable 
response can be made. But the fact remains, that some forms of 
the disease are insignificant, some persistent, and some peculiarly 
liable to relapse from very slight provocation. Only after careful 



140 DISEASES OF THE SKIN. 

weighing of nil the conditions exhibited by the skin and by the 
other organs of the patient, can a reasonable probability as to 
the future be estimated. All this is unsatisfactory, and must 

be so. Eczema is truly a curable disease, but unfortunately one 
not only exceedingly common, but one open to aggravation by 
causes well-nigh innumerable. Were the physician always in 
position to absolutely insure his patient the exclusion of all 

sources of irritation, the prognosis would be much more satis- 
factory. In hospital patients, where such control is more per- 
fectly attained, the results of treatment may be predicted with 
some confidence. 

In general it ma}' he said that acute eczema is more readily 
relieved by proper treatment than the chronic forms of the dis- 
ease, that eczema with a discoverable cause is more manageable 
than one whose etiology is obscure. That eczema of the very 
young, and of the very old, is at times particularly rebellious. 
That the non-discharging phases of the disease are rather more 
persistent than those accompanied by secretion. That eczema 
lingering at the mucous outlets of the body (auditory canal, 
nostrils, mouth, nipple, anus, vagina) is more obstinate than 
when it affects the skin of other parts (shoulder, neck, lumbar 
region). That eczema with constant aggravation or complica 
tions (fissure of the hands, varicose veins of the leg, apparatus 
for anchylosis of knee) is more stubborn in proportion as those 
complications or aggravations cannot, from the circumstances 
of each case, be set aside. And finally, that an eczema which has 
long existed or repeatedly recurred, as for example with every 
season of extremely cold or hot weather, is after relief extremely 
liable to return. 

THE LOCAL VARIETIES OF ECZEMA. 

Eczema of the Scalp. 

When the scalp is affected with eczema, the symptoms differ 
somewhat, according to the age of the patient. In adults, the 
erythematous and srpuamous varieties of the disease are more 
common; in infants and children, the pustular. In the former, 
the eruption is usually circumscribed and in patches; in the 
latter, it is more diffused. In the same proportion also, the for- 
mer is generally asymmetrically and the latter symmetrically 
developed. 

In infants and children, the pustules rupture early; and their 
contents dry into dirty-whitish, yellowish, or greenish crusts, 
matting together the hairs, serving as foci for dust accumulation 
and nests for lice, superimposed upon a reddish, oozing, pus- 
covered or occasionally indolent skin, often foul-smelling, and 
usually complicated by a seborrhcea. The so-called " milk-crust " 
is usually a compound of dried pus and altered sebum. The 
itching is not so intense as in some other forms of the disease. 



ECZEMA. 141 

Post-cervical, preauricular, and occipital adenopathy, are com- 
mon, and in strumous children suppuration of the affected 
glands may occur, though this is rare. The causes of this form 
of the disease are evidently associated with local conditions. 
The rapidly growing hairs of the scalp are in intimate associa- 
tion with the numerous and large sebaceous glands of the same 
part, which unquestionably respond at times to the physiological 
stimulus they feel, by an exudative process. The acne of the 
young man whose beard is growing, illustrates the same fact. 
Local irritants are not often wanting to push the disturbed 
equilibrium into the scale of disease. Dr. White calls attention 
to the common neglect in removing the " pre-natal cap of cheesy 
material," as well as to the rude and unskilful attempts to ac- 
complish the same end. Extremes of temperature, friction, ex- 
cess, neglect and want of skill in washing the scalp, all these 
contribute to originate or aggravate the disorder. 

The affection when complicated or induced by lice, is more 
common in children than in infancy, doubtless in consequence of 
the greater independence of the former and their gregarious 
habits. In female children with relatively long hair, the ova, or 
nits, of the parasite are readily distinguished, adhering closely 
to the hairs and accumulated especially about the occipital re- 
gion. The itching is usually more annoying than in pustular 
eczema not thus complicated. 

The erythematous and squamous forms of the disease, rather 
more common in adults, originate frequently in seborrhcea, 
when scratching or irritant applications have been made. The 
eruption here usually occurs in asymmetrical patches, or may be 
limited to a single patch tolerably well-defined in outline, and 
this often upon one side of the scalp, not as in infancy [(referring 
the vertex. Reference is made in the chapter on seborrhcea to 
a form of eczema of the scalp occurring in adults where finger- 
nail sized, circular, oozing or slightly crusted patches are gen- 
erally disseminated over the surface. They result, as a rule, 
from the scratching of an obstinate seborrhcea in "nervous" 
women; and suggest traumatism, in their reddish friable crusts, 
the color being due to exuded blood. 

The diagnosis of these forms of disease has been already con- 
sidered. 

In the treatment of the eczema of the scalp in infants and 
children, the first indication to be met is the removal of the 
accumulated crusts. When this is harshly accomplished, it be- 
comes a fruitful source of further mischief, it is therefore' neces- 
sary to proceed with great gentleness, and thus the thorough 
softening of the crusts is all important. For this purpose it is 
necessary to soak them in oil and to retain this substance in in- 
timate contact with the scalp. Olive or cod-liver oil may be 
selected, and, if needful to correct the odor or other purpose, 
one drachm (4.) of carbolic acid may be added to each pint (512.) 



142 DISEASES OF THE SKIN'. 

with two drachms (8.) of the balsam of Peru. A neatly fitting 
Bkullcap should be then smoothly applied, constructed of the 
Lister protective or flannel, and fastened in place by a light 
bandage, never by elastic rubber hands. After several hours of 
soaking, the crusts should he removed by warm water an 1 soap 
washing, and the entire process be repeated till the crusts are 
completely detached. In selecting an article for subsequent 
medication of the scalp, it should always he remembered that. 
even infantile eczema will proceed to a natural involution if 
unirritated. Hence the oleated lime-water, or oil of sweet 
almonds alone, will often answer better than an ointment, and, 
even where there is considerable acuity of the inflammatory pro- 
cess, lime-water alone, with possibly a small quantity of glycerine 
added. In other cases the lime-water can he better medicated 
with calomel or the oxide of zinc. At times, also, it is well, 
even when these applications are kept in constant contact with 
the scalp, to order that a small pea-sized mass of one of the oint- 
ments descrihed above (such as the henzoated oxide of zinc 
ointment with cold cream, or medicated with a mercurial com- 
pound) he applied at the time of the dressing. This is to be 
gently rubbed in the surface with the tip of the finger, and the 
skin afterward protected as before. 

It is rarely needful to cut the hair unless nits he found, though 
in public Charities it certainly is a more expeditious method of 
arriving at the end, when a nurse has to dress the heads of several 
children in a single ward. In adults, especially in women, the 
hair should he spared, while the patient is warned that the loss 
of the growth upon the scalp may be considerable. As a sequel 
of obstinate sehorrhcea such an eczema may be succeeded by 
alopecia; in the absence of the former, the hairs are usually 
reproduced. I have never found it necessarv to emplo}^ the 
skullcap in adults, having succeeded in insuring the necessary 
applications by directing the attention of the patient to the 
necessity of care and thoroughness. 

As the disease in both classes of patients advances to a sub- 
acute or chronic stage, the treatment may be changed so as to 
include the various stimulating applications already descrihed, 
such as ointments and lotions containing tar, oil of cade, balsam 
of fir, alcohol, and sulphur. In the case of infants, however, 
such stimulating topical remedies are very rarely to be employed. 
An eczema of the scalp which has once entered upon resolution, 
in an infant or child, should be generalh 7 soothed and protected. 

Many little patients thus affected are in excellent general 
health, and require no internal medication. Others, however, 
demand the interposition of the wisdom of the physician to pro- 
tect them from the ignorance or folly of those to whose charge 
they are intrusted. Here is not space for a discussion of the 
pressing questions relating to the nutrition of the infant de- 
prived of the breast and starving on the " proprietary" diet pur- 



ECZEMA. 143 

chased of a chemist, or an equally vicious aliment compounded 
by lime-water, and imbibed through a tube by which it is 
flavored with India-rubber and the chemically altered casein of 
milk several days old. A word to the wise is sufficient. Fresh 
pure milk, animal broths, cod-liver oil, must not be neglected. 
This, I remark in passing, concerns the health of the child, and 
has indirect connection with the eczema. A record lies before 
me of one hundred infants dead of artificial foods and marasmus 
in a public Charity of this city, and the list discloses not a single 
case of eczema. 

Lastly, patients of both classes are to be saved from mercury, 
arsenic, and the iodide of potassium. 

Eczema of the Face. 

Erythematous eczema of the face in adults is projected promi- 
nently among the varieties of the disease by its uniformity of 
type. It occurs in early and middle life and advanced years; 
and is a particular]}^ intractable ailment. In well-marked cases, 
the forehead, cheeks, eyelids, and nose of the patient are involved, 
exhibiting an infiltrated, usually dusky-red, often symmetrical 
patch of disease, the affected surface being slightly elevated 
above the level of the sound skin. This surface is uniformly 
smooth and reddened: occasionally, near the root of the nose 
and about the lower line of the forehead, minute, closeh 7 set 
papules are visible. Very slight oozing, especially after irrita- 
tion, may be noticed. At the height of the disease or in its 
involution, exceedingly line scales form, which are scarcely per- 
ceptibly shed from the surface. The lids, especially the lower lids, 
in advanced years become puffy. The line of demarcation is 
unusually distinct, and rarely invades the scalp-border or the 
region of the beard in the male. Itching is at times intense, 
the patient complaining of this bitterly, and usually preferring 
to rub the face with the hands or pieces of cloth. Sometimes, 
however, the face is well scratched with the nails, and excoria- 
tions and blood-crusts disfigure the countenance. Patients of 
intelligence usually describe the itching as paroxysmal, and 
starting at the root of the nose, whence it travels upward over 
the forehead, and laterally to the brows, often in the line of the 
supra-orbital nerves. Certainly at the root of the nose, the exu- 
dative process is of the most marked character. The eruption 
also is seen in asymmetrically disposed patches of various sizes, 
with islets of sound skin between. In resolution of the symmet- 
rical form, this is commonly observed. 

Patients thus affected are often those whose faces have been 
especially exposed to irritation, such as locomotive engineers, 
wheelsmen of sea-vessels, mechanics in trades where the hands 
are soiled with irritants and afterward applied to the face, and 
women spending hours of each day over the laundry-tub or the 



144 DISEASES OF THE SKIN. 

kitchen-stove. In each class tlie operation of the cause is made 
manifest by the exacerbation of the disease after exposure. 

The affection is mosl commonly mistaken for erysipelas, a 
disorder from which it is readily differentiated by the ehron- 
ieity of its course. The latter feature is particularly character- 
istic of this form of eczema. It is rarely completely relieved 
utter the age of sixty within a twelvemonth; and, when it has 
existed tor a long period of time, is particularly obstinate under 
the best treatment, recurring with exasperating frequency upon 
exposure of the face to atmospheric changes. The great vascu- 
larity, abundant supply of sensory nerves, and necessary exposure 
of the face, probably explain this peculiarit^v. In its treatment 
the dusting-powders fulfil an important part. Soothing appli- 
cations should always be first employed. The more stimulating 
applications may be tried later. A very intelligent jurist of 
advanced years, whose face was thus affected, consented to aid 
me in some experiments, with a view to determining what ar- 
ticle of external application would give the speediest temporary 
relief for the local distress. He found that strips of cool, raw 
beef, neatly and closely applied over the forehead and cheeks, 
and renewed' as they become heated, were productive of the most 
comfort, an experiment I have since successfully repeated. 

In patients of younger years the face is apt to display vesicu- 
lar and pustular phases of the disease, forms more often of acute 
eczema, and correspondingly more manageable. The itching, 
and especially burning sensations, are apt to be severe; crusts 
form rapidly; and in infants the picture presented is often that 
seen in tne sealp, except that the hairs are not matted into the 
crusts; and there is often a reddish blush at the edge of the 
crust; or, when the latter has been removed, a redness of the 
oozing surface somewhat more marked than the similar patches 
on the less vascular scalp. The scratching in these little pa- 
tients is severe; crusts are torn off in part or wholly; blood- 
crusted excoriations are common The area of surface involved 
in this way clearly extended; sleep is greatly disturbed ; and 
the irritability and fretfulness of the child, thus produced, bear 
heavily upon its general nutrition. In some cases of longstand- 
ing the mental tone of the little sufferers becomes singularly 
perverted, and the character unquestionably changed. They 
will occasionally, when permitted, pick off and devour the 
crusts with voracity, and undergo nervous crises which are but 
a step removed from convulsions, and doubtless allied to the 
petit mat of the epileptic. This chain of formidable symptoms, 
well linked together, will often bid defiance to the most skilled 
efforts to impart ease to the tormented skin. In such cases the 
harness employed by Dr. White, of Boston, fills an important 
office. The skullcap, described above, and made of firm old 
cotton or linen cloth, is closely fitted to the calvarium, and a 
mask of the same material is shaped to the face with exactly 



ECZEMA. 145 

placed apertures for the eyes, nose, mouth and ears. It is 
gathered in beneath the chin, and laps over two inches at the 
back of the head. This may be used only during sleep, or in 
aggravated cases, also during the hours of wakefulness. A 
species of strait-jacket is made by passing the head of the 
child through a hole in the closed end of a small pillow-case, 
which is then drawn down over the body and arms, and the 
latter confined at the sides by stitching the case together be- 
tween the trunk and the upper extremities, or accomplishing 
the same end with safety-pins. The jacket is finally secured by 
similar means between the thighs. When it is necessary to 
imprison the lower extremities, these are similarly secured by 
pins within the case; and the outer edge of such trowsers can 
be fastened to the bed or cushion on which the child reclines. 
Of course this treatment does not preclude the employment of 
the washes, ointments, etc., which are to be neatly applied next 
to the skin beneath the "trowsers" or "-jacket." The result is 
that rest is given to the tormented skin, which is not suffered 
to be exposed to a single scratching even during the dressing 
of the parts ; and its natural tendency to repair soon brightens 
up the case. 

Eczema of the Lips. 

Reference has been already made to the obstinacy of eczema 
occurring near the mucous outlets of the bodj-, a result due, 
I believe, to the secretion furnished bj' the adjacent mucous 
tracts. The lips furnish an illustration alike of this pertinacity 
and aggravation. Their frequent motions in mastication and 
articulation aggravate an eczema, which is, moreover, apt to be 
teased by a no less frequent thrusting of the tongue out of the 
mouth, where there is no beard, to wet the parts with mucus 
and saliva. One or both lips may be involved, vesicular, pus- 
tular, squamous, and erythematous lesions occurring at one 
point, or along the entire line of either, with frequently result- 
ing crusts and fissures. The vermilion border of the lips com- 
monly participates in the process. The lips become hot, some- 
times much thickened by the swelling and infiltration, their 
mucous faces being rarely implicated. Scarlet, dull red, and 
other peculiarly purplish hues of the vermilion border become 
visible. The parts are more picked than scratched, though the 
itching is at times severe. The pustular and vesicular forms 
are more common in children. The erythematous form, its red- 
dened outline roughened by scales, evenly projected beyond the 
vermilion border, is rather an affection of maturer years. In 
young children the affection is frequently aggravated by nasal 
discharges which flow over the lip, giving the latter an elephan- 
tiasic aspect, a condition noted also in later life. Occurring 
upon lips covered with the hairs of 'the moustache, the disease 
exhibits the usual symptoms of eczema barbae. In these male 
10 



146 DISEASES OF THE SKIX. 

patients, the pipe, the cigarette, the cigar, and the tobacco 
chewed and expectorated may aggravate the malady.' In all 
c;i-,.. it is obstinate, and calls for either emollient, stimulating, 
or protective applications. In cases displaying acute and pain- 
ful symptoms, frequent fomentations of the part with soft rags 
dipped m mucilaginous and alkaline hot waters, will aid in con- 
trolling the swelling and alleviating the pain. In chronic cases, 
where stimulation is demanded, this can be effected at the time 
of dressing, the parts being subsequently protected by collodion 
or other material. Carbolic acid and the nitrate of silver are 
often needed for Buch dressing. In eczema of the hairy lip it is 
often of great service to remove the moustache by shaving. 

The diagnosis is between sycosis parasitaria, herpes labialis, 
and epithelioma, the points of difference having been already 
suggested. The first is accompanied by loosening of the hairs 
and caused by a parasite; the second is vesicular in lesion, brief 
in duration, and trivial in severity; the third is a disease of 
advanced years, rather than of early and middle life, and is never 
accompanied by itching, but usually by more or less ulceration. 
Syphilis is fond of the angles of the lips; in most cases when 
thus limited, typical mucous patches of the mouth can be dis- 
covered. 

Eczema of the Nose 

Is naturally often associated with a chronic coryza. Inasmuch 
as one of the common symptoms of hereditary syphilis is the 
" snuffles" of the child, the physician should carefully exclude 
the possibility of such disorder in every instance when an infant 
with a coryza exhibits an "eczema" of the nose or lips. The 
age of the little patient; an inspection of its anal region (which 
should never be omitted in infantile eczema); and the history 
of the case will throw considerable light upon this important 
question. 

Whether occurring in the adolescent or child, the disease may 
linger only upon thealae in pustular or squamous forms, or block 
up the nares with crusts. In infants this enforces respiration 
with an open mouth, and the grasp of the nipple by the lips is 
thus interrupted either by respiratory acts or cries of agitation. 
The Schneiderian membrane participates in the inflammatory 
process, and pours out its secretion upon the eczematous skin. 
The membrane when inspected is seen to be either raw and suc- 
culent, or in a condition analogous to the pharyngitis sicca of 
authors, dry, glazed, and free from discharge. The nostrils are 
often thickened in consequence of the infiltration or fissured, 
especially at the line of the nares laterally and inferiorly. In 
severe cases, and when the lips participate in this process, the 
pouting, swollen, and distorted organs suggest the snout of the 
lower animals. Adults as a result frequently surfer from non- 
parasitic sycosis and furunculosis. 



ECZEMA. 147 

Care should be taken to exclude syphilis in making a diag- 
nosis, bearing in mind the fact, that the pustular syphiloderrn 
(which see) frequently selects the furrow on either side of the 
nares for its evolution. 

In treating these cases all crusts should be removed, and the 
parts carefully protected. Picking the nose in children should 
be prevented if needful by the " strait-jacket." Pencillings with 
the compound tincture of benzoin, iodized phenol, nitrate of 
silver, and collodion will often prove serviceable. In softening 
crusts, oil may be freely used. For this purpose the warm car- 
bolized spray of the atomizer answers well. 

Eczema of the Ears. 

The ears are affected with eczema both in infancy and maturer 
years, the disease being limited to the whole or part of the organ, 
or extending backward over the post-auricular region or down- 
ward over the ramus of the superior maxilla. It may originate 
in chronic catarrhal discharges from the external auditory me- 
atus ; in exposure to temperature changes, especially when aided 
by high winds; in frost-bite ; in the irritation set up by the 
auricular limb of the frame of spectacles; in the toxic effect 
induced by the hook of cheap ear-rings and dyed bonnet rib- 
bons ; in the traumatism of ear piercing; and in the habit of 
unnecessarily picking the ear to relieve it of wax or trifling 
sensations of irritation. 

The pustular and moist forms are common at the superior, 
inferior, and posterior boundaries of the pinna, where a linear 
fissure is apt to form in the line of the angle made by the auricle 
with the plane of the adjacent integument. The motions im- 
pressed upon the ear by handling it, placing the hat on the head 
and tying hat strings over it, always tend to aggravate the dis- 
order. Long hairs worn over the ears may have a similar effect 
by the production of friction and the retention of heat. The 
lobules are apt to display the erythematous and scaly phases of 
eczema, becoming infiltrated, having a deformed appearance, a 
lurid red color and indolent course. The lobules alone of both 
ears in young women may be similarly affected, and exhibit 
these phenomena for consecutive years. Often the chronic in- 
flammation may laj^ the foundation for a keloidal growth, an 
accident of several inflammatory processes in other parts. At 
other times the entire auricles present a similar appearance, uni- 
formly dark red, infiltrated, alternately weeping and scaling, 
and projecting to a noticeable extent from the side of the head 
in consequence of their increase in bulk. The itching is usually 
more annoying than severe, being accompanied by a character- 
istic sensation of tenseness and fullness of the part. Like the 
eczema which occurs at the other mucous outlets of the body, 
the affection in these parts is particularly obstinate when it 



148 DISEASES OF THE SKIN*. 

assumes the chronic form. Symmetry to the extent of involving 
both ears, though commonly to a different degree in each, is 
rather the rule than the exception; and is doubtless due to the 
simultaneous operation of a common cause. 

The diagnosis is between erysipelas, seborrhcea (which occa- 
sionally occurs in the concha of the auricle), erythema simplex 
and multiforme, and dermatitis calorica. 

The treatment should be at first soothing and protective; 
afterward stimulating. A firm bandaging of the ears to the 
head may he required to support the parts, to prevent irregular 
pressure (head upon the pillow), and to secure contact with ex- 
ternal medicaments. In chronic cases, stimulant applications 
are often well tolerated, and the tarry ointments here play an 
important part. Treatment appropriate to the otitis externa 
may be required. Bulkley recommends a tannin ointment, one 
drachm to the ounce, deeply and thoroughly passed into the 
meatus on a camel's-hair brush. French authors generally re- 
commend small tampons smeared with an ointment, and left in 
the canal. I have often found the greatest benefit from pencil- 
ling the indolent surfaces with solutions of the silver nitrate. 
The intractable forms almost invariably affect adults, and in 
them there is usually a history of improvement under treat- 
ment, then, in males, exposure, as, for example, to the wind, or, 
in females, excessive dancing, etc., and subsequent aggravation. 

Eczema of the Lids. 

Here the free edge of the lid, or the skin over the orbital mar- 
gin of the tarsal cartilage, may be chiefly affected; and either, 
both in children and adults. When the free edge of the lid is 
involved, there is a species of sycosis non-parasitica present, the 
hair follicles becoming inflamed and furnishing a purulent dis- 
charge which may agglutinate the lids. The latter are thickened 
and swollen, become'the seat of a moderate itching, are picked 
rather than scratched, and exhibit, minute crusts between, or 
glued to, the hairs. The disorder is often accompanied by a se- 
borrhcea of the Meibomian follicles, ami is described by oculists 
under the designation of " blepharitis" and "tinea tarsi." Inas- 
much as the facial expression is quite characteristic when the 
lids are thus involved, the patients exhibiting this form of eczema 
are usually set down as "scrofulous," though I am confident it 
occurs in many individuals with no other sign of struma, and 
eczema surely is not such a sign. 

Fissures occasionally form at the commissure of the lids. The 
disorder may complicate eczema of the other parts of the face. 
In the erythematous eczema faciei of adults, there is usually 
swelling with puffiness, especially of the lower lid. The con- 
junctiva may. or may not, be implicated. A chronic granular 
condition of the lids is not noted as frequently as might be sug- 
gested by a -priori reasoning. 



ECZEMA. 149 

The edges of the lid should be carefully cleansed with a weak 
alkaline solution and soft camel's-hair brush, whenever the lid 
itself is involved ; then as carefully dried and anointed with cold 
cream. In acute cases, the closed lids may be frequently bathed 
with warm alkaline solutions; and strips of soft lint, soaked in 
the same material, or a very dilute glycerine and carbolic acid 
solution, may be laid over the closed lids for as long periods 
during the day as they are comfortably tolerated. In chronic 
cases, the red oxide of mercury ointment, half to one grain 
(.033-066) to the ounce (32.), has always been held in high esteem. 
The oculists, in the treatment of this affection, are fond of using 
an ointment of the yellow sulphuret of mercury. Epilation of 
the eye-lashes may be, rarely, necessary. Pencillings with solu- 
tions of the nitrate of silver in various strengths, are also useful 
in chronic cases, but these must be carefully confined to the lids 
and not suffered to come into contact with the conjunctiva. 
Excessive use of the eyes must be prohibited. 

In the diagnosis, care must be taken to exclude syphilis, lupus, 
and pediculi. I have seen but one instance of piedra of the eye- 
lashes, and do not recall any description of that disease in this 
locality. Instead of the ordinary nits of the lash, there were 
in this case, jet-black, small pin-head sized masses of ivory-like 
hardness, attached to the hairs. 

Eczema of the Beard. (E. Barbse.) 

Eczema may involve the region of the beard only ; or may 
spread to such parts from those in the vicinage ; or may, finally, 
extend from the beard to other parts of the face. The first is 
common, and furnishes, perhaps, the best type of the disease; 
the second is also common, but usually subordinate in importance 
to other trouble of the facial region. The last is decidedly the 
rarest. It is indeed a matter of surprise that an eczema should, 
as it often does, endure for years limited exclusively to the re- 
gion of the beard, and never once transgress these limits. 

In this last-mentioned fact, I find a convincing argument in 
favor of the local origin and of the frequency of local sources of 
aggravation of eczema. Rarely will one see a picture more sug- 
gestive to the uneducated eye of "scrofula" or "humors of the 
blood," than the face of a middle-aged man, with long standing 
eczema of the entire region covered by the heard. The hairs are 
thinned and fail to hide completely the reddened surface beneath ; 
covered here and there with pustules or floors of broken pustules, 
dried inflammatory products, scales and crusts. Beneath the 
crust the surface is smooth, not lumpy as in parasitic sycosis. 
The hair follicles are not solely involved, as in the non-parasitic 
form of sycosis, but evidently they and also the integument be- 
tween them. In recent eczema the hairs are not loosened in 
their follicles, but in chronic cases such loosening does unques- 



150 DISEASES OF THE SKIN. 

tionably occur, and there is a true defluvium eapillitii. The 
disorder is evidently one primarily involving the skin of the re- 
gion of the heard, and secondarily the hairs, extending smoothly 
over that surface, as smoothly as an eczema on the cheek of a 
woman. There is commonly a certain degree of symmetry, to 
the extent at least of involving the beard in different degrees 
on both cheeks at once, or the chin on both sides; often the 
symmetry is perfect. This is rare in the parasitic affection of 
the aame part. 

The disease is accompanied by itching, rarely as severe as upon 
the smooth parts of the face, is particularly obstinate and ex- 
tremely disfiguring. When extending into the region of the 
heard from other parts, it is usually associated with eczema of 
the ears. When limited to the region of the moustache, it may 
be connected with an eczema of the nares and a chronic nasal 
catarrh. 

The explanation of the obstinacy of eczema of the region of 
the beard is, I believe, to be found solely in the hairs which 
cover it. Whether the latter be long or short, feeble or strong, 
each during the entire twenty-four hours, acts to a certain extent 
as a lever in motion upon the portion of the integument in which 
it is implanted. In conditions of health, the skin tolerates well 
this motion ; in disease it becomes a positive source of trouble. 
Multiply by thousands the impression produced upon the healthy 
skin when a single hair or group of hairs is moved by a strong 
current of air, by the fingers, by a brush, or by any other exter- 
nally operating cause, and some idea may be had of the extent to 
which this force may become effective. But the best evidence of 
the fact is to be found in the results which follow the removal of 
the beard. Clipping short the hairs of the face will not answer, 
though generally preferred by the patient as exposing to a less de- 
gree the unsightly surface beneath. Nothing short of shaving 
and continual shaving every second day, will effect the desired 
result in chronic cases. As soon as the disease is reduced prac- 
tically to an eczema of the non-hairy parts, it improves, in pro- 
portion to its distance from the mucous outlets of the body. 
When limited to the bearded cheeks, the most obstinate cases 
may be in the course of a single month robbed of one-half of their 
unsightliness. It may be needful to employ the usual methods, 
oil. hot water and soap, to remove the crusts before the first 
shaving, and any imprisoned pus should be evacuated. The pa- 
tient should be encouraged by reminding him that usually it is 
but the first step which costs; each succeeding removal of the 
beard is accomplished with greater comfort to himself physically 
and mentally. After each shaving, the skin should be bathed in 
water as hot as tolerable, and if at night, a lotion may be used 
or an ointment, or the latter after the former. Best of all, how- 
ever, is the dusting powder; and, as soon as practicable, the pa- 
tient should limit himself to this application. The shaving 



ECZEMA. 151 

should be continued for months after the disease is at an end. 
It is indeed surprising to note in such cases how quickly the 
"scrofulous" look disappears, and the evidences of a " humor of 
the blood " are no longer evident in the face. The longer the 
limitation of the disease to the region of the beard, the more 
brilliant, as a rule, is the result. I have rarely found it neces- 
sary to resort to the tarry applications in this forn^of the affec- 
tion. When complicated by eczema of the post or infra-auricu- 
lar region, stalactite-shaped crusts depending from the infiltrated 
lobule in consequence of the unintermittent drip of serum from 
above, eczema of the region of the adjacent whisker is less readily 
managed. 

Flat epitheliomata of the bearded cheek are not to be con- 
founded with eczema barbae. The points of difference have 
been previously noted. It should be remembered, also, that 
the age of the patient, the career of the disease, the possible 
eversion of the neighboring lid, or agglutination of the adjacent 
lobe of the ear, distinctly high elevation, or ulceration of tissue, 
absence of itching, and distinct localization of the disease, are 
all characteristic of this form of carcinoma. 



Eczema of the Genital Organs. 

Here the disease is remarkable for the severity of the sub- 
jective sensations it occasions; for its tendency to persistence, 
recrudescence, and nocturnal exacerbation ; and for the liability 
to the production of the sexual orgasm by the act of scratching. 
In the male the surface most often involved is the anterior, pos- 
terior, or lateral faces of the scrotum where they meet the thigh, 
though the surface of the penis, as also that of the pubes and 
perineum, may be involved. In the female, the labia majora, 
more rarely the labia minora and vestibule of the vagina are 
affected, with occasional extension of the disease to the same 
contiguous parts as in the male. 

Eczema thus located is, as a French writer has well said, " a 
dry disease in a moist locality." Vesicular and pustular forms 
are much rarer than the erythematous, the papular, the papulo- 
squamous, and the erythemato-squamous. In the female, the 
moister forms are more frequent, doubtless because of the wider 
mucous outlet, and the more extensive mucous tract in the 
vicinage. The labia are then heightened in color, cedematous, 
agglutinated by crusts, and often torn viciously by the finger- 
nails. Blood-crusted excoriations are seen in most severe cases. 
An eczema intertrigo at the labio-femoral angle is common. 
Over the whole may be poured the secretions from uterus or 
vagina, normal or pathologically altered. The disease is, how- 
ever, sufficiently common after the menopause, when there is 
physiological atrophy of the uterus. 

The typical disease in the male is recognized in the thick- 



I'y2 DISEASES OF THE SKIN. 

ened, reddened, perhaps slightly scaling integument of the scro- 
tum, which may also be fissured, excoriated by the nails, or cov- 
ered by blood-crusts. Torn papules, often closely packed together, 
may be seen with a peculiarly lurid, even purplish bue. Tn 
exaggerated cases the infiltration is so great as to deform the 
pari-, increasing the thickness of the scrotal integument to 
many times its normal dimensions, producing thus an elephan- 
tiasic appearance. In eczema of the penis the prominent symp- 
toms are also oedema, itching and redness, with slight scaliness. 

In both sexes, :is before intimated, the attempts to relieve the 
itching are often as severe and prolonged as they are ingenious. 
Commonly no relief is obtained till a serous sweating or weep- 
ing of the thickened tissues is induced hy the friction. Inas- 
much as the latter is in severe cases frequently repeated, the 
physical dangers are obvious. 

Apart from this, however, the disorder has a marked tend- 
ency to disturb the mental tone and the general health. Shame 
deters many from seeking speedy relief, so that cases of long 
standing are those more commonly registered by the physician. 
Though entirely unconnected with venereal disease of every 
kind, there is, for the many, a special dread of an eczema of 
these parts, precisely because of its location. With Bleep dis- 
turbed, the mind agitated, and the nervous system teased by an 
intolerable pruritus, one can scarcely wonder at the eloquence 
with which many patients describe their sufferings. It is a 
disease of middle life and advanced years. I have never seen 
a well-marked, obstinate case in a child. 

The causes, exciting and aggravating, of eczema of the genital 
region, are to be sought in heat, moisture, and friction. These 
primary factors are favored, — first, by the effect of gravity, the 
organs in question being situated, when the body is in the erect 
position, at the inferior apex of the double cone forming the 
trunk, and being thus subject to the force of gravity; second, 
by the arrangement of the clothing in both sexes, by which heat 
and friction effects are heightened ; third, by uncleanliness, the 
secretions and discharges from the adjacent mucous tracts being 
suffered to accumulate upon the person ; fourth, by a long list 
of sexual errors which operate by obstructing what may well 
be termed the sexual ebb — that is, the natural reflux by which' 
each periodical physiological congestion of these organs is by a 
natural process relieved. That the skin of these organs partici- 
pates in such periodical congestion is a fact demonstrable to the 
eye. The abundant supply of bloodvessels, lymphatics, and 
nerves to the parts, furnishes all necessary elements for the ex- 
planation of the formidable series of symptoms often displayed 
in eczema genitalium. 

A curious illustration of the illogical method of drawing con- 
clusions, unfortunately too common in medicine, is furnished 
by the fact that in many eczemas of the surface, especially of 



ECZEMA. 153 

the genital organs, the urine will be frequently found to contain 
albumen or sugar, and these conditions have been supposed to 
lie at the root of the eczema. One author has even gone so far 
as to prescribe a diet for the eczematous patient with saccharine 
urine. The explanation of the phenomenon is, however, suffi- 
ciently simple. It is the eczema which causes the elimination 
of the sugar or albumen, and not the reverse. The demonstration 
of the fact is readily made. Sugar and albumen are known to 
be producible in the urine by external irritants, and, among the 
latter, by cutaneous diseases. Merely varnishing a portion of 
the skin has been followed by these effects. If the patient with 
saccharine urine and severe genital eczema can be kept in bed, 
in the recumbent position, for a few days, while any soothing 
application productive of comfort is continuously applied to the 
tender and excoriated surface, the sugar will be found to rapidly 
disappear from the fluid excreted from the kidneys. I am in- 
clined to the belief that these renal symptoms are in part reflex, 
resulting from the extraordinary irritation of the nerves dis- 
tributed to the involved surfaces. 

The treatment is to be conducted on the general principles 
heretofore enunciated. Sponging of the genital region with 
alkaline water as hot as can be well tolerated, followed by the 
blander oils and ointments at night, and the use of anti-pruritic 
dusting powders in the daytime, must not be omitted. In 
eczema of the scrotum, the suspender lined with lint which is 
wet with a lotion, smeared with an ointment, or thoroughly 
covered with a powder, can be usually employed to good advan- 
tage. The habit of scratching must be broken up at all hazards. 
In chronic cases, the treatment by soft soap and diachylon oint- 
ment will be found useful. Caustics, solutions of the mercuric 
bichloride, and other mercurials, carbolic acid, and especially 
the tarry compounds, are often necessary. 

Finny, of Dublin, uses the following formula?, which I have 
found to be exceedingly useful in allaying the irritation: — 



M. 



i,. Liniment, calcis. f^iv ; 

Belladonn. extr. gr. xij ; 

Zinci oxyd. 3ij 5 

Glycerini. f^ij ; 

Aq. calcis. f§iv ; 
ig. "Lotion, to be applied at night after 

water." 


130 

8 

8 

130 

bathing 


V. Lin. calcis. f §iv ; 
Acid, hydrocyanic, (dil.) ^iv ; 
Liq. plurabi subacetat. f.^ij ; 
Glycerin. f5u ; 
Aq. ros. ad. fgviij ; 


130 

15 

8 

8 

280 



Sig. " Cream, for application on strips of old linen." 

Exceedingly obstinate eczema of the pubic region is benefited 
by shaving and subsequent appropriate treatment. When com- 
plicated by an intertrigo, the latter condition requires special 
relief by the interposition of soft lint spread with an ointment. 



154 DISEASES OF THE SKIN. 

Tlio diagnosis is between ringworm of the genitals, acne, 
pruritus, pediculosis, the venereal disorders, and herpes progen- 
1 talis. The 6rs1 named may occur alone, or induce, or be grafted 

upon the eczema. Ir will be recognized by the discovery of the 
trichophyton, and is clinically distinguished by the crescentic 
edge of the spreading patch, with its convex border looking 
away from the genital centre. The "follicular vulvitis*' of 
gynecological authors is a genital acne, and manifestly limited 
to the glands and peri-glandular tissues. The same is true of 
bromine and iodine acne, which I have seen developed in the 
same situation in both sexes. Genital pruritus may beget an 
eczema by scratching, hut is accompanied by no proper skin 
lesion. The pubic louse is visible to the eye, as are also its nits. 
The ulcers and sclerosis of the chancroid and primary syphilis 
are not accompanied bv pruritus, and though occasionally mul- 
tiple, never exhibit diffuse patches of disease. The syphiloder- 
mata are recognizable by their characteristic features, and by 
the history of an infectious disease. In herpes progenitalis 
there is precedent, burning, smarting, or neuralgic sensations, 
the occurrence of vesicles or groups of vesicles (lesions rare in 
eczema of the genitals), and frequent limitation of the disorder 
to the mucous surfaces or the muco-cutaneous lip by which such 
surfaces are bounded. In eczema such boundaries are usually 
respected, and the disease is much more strictly cutaneous. 

Eczema of the Anus and Anal Region 

In its etiology and characteristics is closely allied to the same 
disease in the genital region. The presence of ascarides and 
haemorrhoids occasionally induces or aggravates the disorder; 
though I believe this is rarer than is commonly taught, since 
multitudes of men and women who suffer from piles never com- 
plain of eczema. The eczema may occur in erythematous, 
squamous, or papular form, in the order named; thus exhibit- 
ing here, as in the genitals, "a dry disease in a moist locality." 

The redness, infiltration and itching may he limited to the 
verge of the anus, radiate from the latter in stellate lines, creep 
upward between the nates in the cleft, sweep forward over the 
perineum to the genital region, or extend laterally with inter- 
mediate intertrigo over the inner face of each thigh. Rarely 
the buttocks are covered with the same lesions. 

The disease is common in infancy, where want of care in the 
removal of the napkin is a fertile source of mischief; and also 
in middle life and advanced years, when it becomes particularly 
intractable. The itching is intense in the latter class, with fre- 
quent nocturnal exacerbation. Unfortunately the scratching is 
often reflex, and practised during the unconsciousness of sleep, 
from which the patient is often roused by his or her manipula- 
tions. Pollutions fully recognized, or occurring during pro- 



ECZEMA. 155 

found sleep, or, more usually, in states of semi-consciousness, 
complicate certain cases. The harassed nervous system of the 
sufferer is often in a deplorably wretched condition. In cases 
of long standing the usual congested, thickened, infiltrated, and 
almost elephantiasic appearance is presented, with exaggeration 
of the natural furrows and occasionally fissures. The part may 
simulate in aspect the formidable conditions discovered in pas- 
sive pederasty. Excoriations are common around the anal verge. 

The diagnosis is that of eczema of the genital region. 

In the treatment of these cases the use of very hot water by 
sponging, and the subsequent application of ointments, bus 
yielded the best results. In the case of infants the dusting 
powders and blander ointments are alone to be employed; in 
adults, especially in chronic cases, the tarry applications are 
especially valuable. Here the tincture of tar may be freely 
painted over the surface, or one of the tarry ointments of suffi- 
cient firmness to retain its form as an unguent when subjected 
to the heat of the part. Caustics are useful when there are fis- 
sures. Corrosive sublimate, one-half to one-quarter of a grain 
(.033-016) in the milk of almonds; Squire's glycerole of the 
plumbic subacetate, half a drachm (2.) in two ounces (60.) of 
glycerine and water, or, as a substitute for the latter, the soft 
soap and diachylon plaster are here of special service. When 
defecation is painful the stools should be rendered soluble in 
order to insure non-aggravation of the local disorder; not, it 
need scarcely be remarked, with a view to eliminating any 
materies morbi by purgation. I have occasionally found service- 
able small tampons of cotton smeared with an emollient oint- 
ment, and gently inserted for a short distance within the anus. 
Kaposi recommends butter of cocoa suppositories, containing 
zinc oxide with belladonna or opium. When complicated by 
true fissure of the anus the sphincter ani must be stretched, 
divided, or dilated with medicated bougies. 

Eczema of the Nipple and Breast of the Female 

Is common in nursing women from either the irritation pro- 
duced by the mouth of the infant, or, more commonly, in con- 
sequence of a galactorrhcea. Eczema intertrigo is common below 
and between the breasts. The eczema here is vesicular, erythe- 
matous, or squamous in form, with fissures of the apex, side, or 
base of the nipple. The serous ooze from the infiltrated areas 
dries as usual into light-colored crusts. The disease may occur 
on one or both breasts, and, especially with a galactorrhcea in 
summer, may spread extensively, covering both breasts, the sur- 
face of the belly and the intermammary region. The circum- 
scribed forms occur also in pregnant or unmarried women, and 
are to be distinguished from scabies, which in the female is apt 
to occur upon the breast. 



156 DISEASES OF THE SKIN. 

"Paget's disease," the Bo-called eczema of the nipple and can- 
cer of the breast, is designated by Thin 1 as a destructive or a 
"malignant papillary dermatitis." The mammary tumors here 
formed are found to originate in the epithelial lining of the 
lactiferous ducts, the elements of which undergo, at an early 
period of the disease, a cancerous transformation. Clinically, 
there is usually observed in such cases, a sunken nipple, its site 
occupied by a bright red infiltrated patch of distinct outline, 
differing thus from the irregular definition of the contour of the 
eczematous area. In all cases of subcutaneous tumor or coinci- 
dent axillary adenopathy, the physician should be especially 
careful in the matter of prognosis. 

The treatment is in general that described above. In severe 
cases with galactorrhcea nothing short of weaning the child, 
and a cessation of all demands upon the breast will insure relief. 
Every effort should be made in milder cases to avoid this dernier 
ressort. At first, scrupulous care; pencillings of fissures with a 
crayon of silver nitrate; gentle anointings with emollient zinc, 
thymol, or carbolic acid ointments, which should be carefully 
washed off before the child is put to the breast; and finally, 
dusting powders witli soft lint retained between and beneath 
the breasts, are measures to be tried. Later, the sublimate solu- 
tions, diachylon ointment or naphthol, two per cent, in alcohol, 
may be employed. Founder recommends a breast-plate of 
caoutchouc. When limited to the nipple and areola in nursing 
women the glass and rubber apparatus sold in the shops may be 
tried in the hope of saving the nipple from the mouth contacts 
in nursing. Sometimes they answer admirably; often they fail 
utterly. 

Eczema of the Umbilicus. 

This local variety of the disease is briefly described in the 
chapter devoted to seborrhoea. In most cases it is either in- 
duced or aggravated by a local seborrhoea fluida, which gives 
origin to the peculiarly nauseating odor characterizing the dis- 
ease. Generally a reddish and infiltrated, more or less annular 
patch surrounds the umbilical depression, which may be filled 
with crusts. Syphilodermata, pediculosis, and scabies in women 
{ire to be carefully excluded in the diagnosis. The liquor soda? 
chlorinate, carbolic acid solutions, and, in chronic cases, iodized 
phenol will be required in its management. Care should be 
taken that the dressing of the navel in the newly born infant, 
the improperly adjusted apparatus for retention of an umbilical 
hernia, and the corsets or " uterine supporters" of the female, do 
not occasion or aggravate the disease. 

1 London Lancet, June, 1881, Amer. ed., p. 533. 



ECZEMA. 157 

Eczema of the Superior and Inferior Extremities. 

The flexor surfaces of the extremities, especially in the vicin- 
ity of the joints, are particularly prone to exhibit symptoms of 
the disease. With these should be properly included the axil- 
lary and inguinal spaces. In all such localities the alternate 
tension and relaxation of the integument serve when the limbs 
are in motion, to increase the pruritus, and, correspondingly, to 
aggravate the disease. Often a certain degree of symmetry can 
be perceived, the two popliteal spaces, for example, being simul- 
taneously affected, though each to different degree. The parts 
most favorable for the complications of intertrigo are those 
nearer the trunk where the moisture and heat are greater, as 
the groins and axillae, while the elbow and popliteal spaces are 
more frequently dry, exhibiting papulo-squamous ridges in lines 
at right angles to the axes of the limbs, with hypenemic patches 
on either side. 

Upon the legs, where the force of gravity is more potent than in 
other parts of the body, exaggerated forms of eczema are found 
complicated with varicose veins and oedema, with dense infiltra- 
tions and indurations. In ancient cases the frequent elephanti- 
asic aspect is significant, one limb being by several inches larger 
in circumference than its fellow, covered from knee to ankle 
with enormous patches of eczema rubrum of an intensely angry 
appearance, moist and crust covered; or dry, glazed, and of a 
lurid reddish hue; or dry, horny, and ridged with irregular 
projections surmounted by scales resembling the rough bark of 
a tree; or again, with or without oedema, tense, inelastic, seamed 
with scars of old varicose ulcers, and deeply and irregularly pig- 
mented, an appearance with great difficulty to be distinguished 
from syphilitic ulceration of the same region. At its onset, 
eczema of these parts may assume any one of its known forms. 
In infants with long clothing, where the lower extremities are 
subjected to a higher temperature than in adults, the vesicular 
and pustular forms are common. The exceedingly obstinate 
forms of eczema of the legs, especially those complicated with 
varicose veins, are, of course, those encountered in middle life 
and advanced years. 

The diagnosis is in general to be established by considering 
the points heretofore discussed. The chief difficulty lies in dis- 
tinguishing the eczema associated with ancient varicose cica- 
trices of the leg, from syphilitic scars of the same locality, which 
have resulted from degenerating tubercular syphilodermata or 
gummata. In some cases when no distinct history can be ob- 
tained, there will be a necessary doubt, as the force of gravity 
upon the vessels, even without varicosities, produces certain 
common features, notably deep pigmentation, in both classes ot 
cases. In women, the sexual history is all-important, including 
the order of abortions, miscarriages, and viable infants. In both 



158 DISEASES OF THE SKIN'. 

sexes, the discovery of other lesion-, and especially of character- 
istic cicatrices elsewhere, musl be attempted. It will be re- 
membered that the syphilitic ulcer tends to the shape of a circle 
or segment of a circle, and though occasionally existing as the 
sole lesion upon one leg, it is frequently multiple, or may involve 
both extremities, the pigmentation in old cases occurring chiefly 
at the periphery of the sear. Very extensive pigmentation 
about ancient cicatrices, especially disposed between irregularly 
defined seal's, is truer of eezematous forms, as the pigmentation 
due to syphilis, though long-lived, is yet the more ephemeral. 
With periosteal nodes the diagnosis is clearer. 

The treatment of eczema of the extremities does not differ 
from that described above, except as regards the indications to 
he met relative to support of the parts, thus counteracting the 
effect of gravity. Excellent results are here obtained by the 
use of the pure rubber bandage, applied immediately next the 
skin, especially in cases complicated by oedema, ulceration, and 
venous varicosity. The method of applying the well-known 
Martin bandage has been made generally familiar to the profes- 
sion ; and for details respecting its availability in eczema of the 
leg, I refer the reader to the essay on Eczema and its Manage- 
ment, by Dr. Bulkley, of New York, 1 who is enthusiastic in its 
praises. 

Such treatment, however, deserves only subordinate rank in 
comparison with the essential rest of the affected limb in the 
horizontal position. With a grave eczema of the lower ex- 
tremity, such rest should be enforced ; and patients whose limbs 
have proved rebellious under the rubber (for such there are) may 
thus be relieved The local applications to be made meanwhile 
are those adapted to the particular features in each case present. 

To a less degree, the same may be said of the arms. In these 
localities, I have never found it necessary to resort to elastic 
pressure. In all cases, however, a neatly-applied bandage over 
the dressings will add the effect of pressure and support, and 
generally contribute to the comfort of the patient. 

A favorite dressing with me, in dry, papular, erythematous 
and squamous patches of the disease, is applied as follows: — 
The parts are first bathed with hot alkaline water for several 
minutes till the itching is relieved, and then carefully and 
thoroughly dried. The^ patch is then completely covered with 
a dusting powder, which, according to the indications of the 
case, is either emollient, astringent, or stimulating. Finely pow- 
dered tannin with French chalk, or even pure calomel, or bis- 
muth, zinc and starch, may be thus used. Over the whole, strips 
of Maw's surgical plaster are alternately and neatly superimposed 
in the manner some years ago recommended by Baynton. A 
snugly fitting rubber bandage encompasses the whole. The 

• G. P. Putnam's Sons, N. Y., 1881. 



ECZEMA. 159 

dressing is left in situ as long as it is comfortable, often for two 
or three days, when it can be removed. In properly selected cases, 
the itching is relieved, the infiltration reduced, and the patch 
soon loses its hypera?mic aspect. Occasionally no other treat- 
ment will be required. 

Nor should it be forgotten that with care and patience, the 
starch bandage of the leg, the plaster of Paris dressing over folds 
of Canton flannel arranged so that it may be removed at pleasure 
in the manner in which it is used by some surgeons in the treat- 
ment of diseases of the joints, these and other immovable dress- 
ings may accomplish even more in obstinate cases than elastic 
apparatus. 

Eczema of the Hands and Feet. 

E"o more striking illustration of the significance of the etiology 
of eczema can be adduced than that to be discovered in the 
hands. By these organs man toils to earn his bread, and the 
eczema they display is their protest against the rude contacts 
which are thus necessitated. Unfortunately, in too many of such 
patients, the imperative necessity of such bread-winning, forbids 
consent to the best method of relief, viz., temporary disuse of 
these organs. 

The feet may or may not be similarly attacked, and for similar 
reasons. All forms of eczema are here seen, erythematous, vesic- 
ular, papular, pustular, and squamous, involving the entire sur- 
face, or limited to the wrists, ankles, interdigital spaces, palmar 
or plantar surfaces, or one or more digits on either face. The 
motions of the part are so free, that fissures are common and 
often exceedingly painful. The itching may be severe, and the 
parts of one hand or foot extensively rubbed, torn, or abraded 
by the other. Vesicles are more frequently encountered upon 
the more delicate portions of the skin, as over the dorsum and 
interdigital spaces, while in the denser palm and sole they are 
represented by sub-epidermic points from which by puncture a 
clear serous or cloudy fluid may be evacuated. Usually, how- 
ever, in the regions last named', there is a dry, dead-whitish or 
hypereemic, uniformly indurated and thickened integument, 
which may be lissured or produce such a tense inelasticity of 
the surface that the fingers are semi-flexed into the palm, or, 
much more rarely, the toes rendered considerably less extensible. 

Circumscribed patches of eczema, with fairly defined outline, 
reddish in color beneath crust or scale, subacute in course and 
accompanied by paroxysmal itching, are of common occurrence 
on the dorsum and also in the' palm or sole. In the latter situa- 
tion, they may be traversed by one or more painful fissures, the 
same being true of the dorsum of the fingers and toes. Upon 
the back of the hand, these circumscribed patches are apt to as- 
sume an indolent course, improving temporarily under appro- 



160 DISEASES OF THE SKIX. 

priate treatment, and becoming aggravated by every exposure 
to the causes by which they were first induced. 

The long list of etiological factors which may here be efficient 
can scarcely be enumerated. Several have already been considered 
in discussing the causes of eczema in general. The influence of 
all articles handled in the trades, occupations, and professions of 
life, as well as of the action of toxicants and dye-, must be 
remembered. Thus printers, bakers, and masons suiter in the 
hands; and the wearer of dyed stockings, and coarse, ill-fitting 
shoes and hoots in the feet. Because needle-women are often' 
overworked, nervous, pale, and thin, their digital eczema, really 
due to the implements and stutl's they handle, has heen erro- 
neously attributed to the general condition. I have seen the 
poor seamstress starving for sunlight, nutritious food, and open 
air exercise, return to her weary routine with her eczema quite 
relieved. 

The treatment demands, first, rest for the organs, and a simul- 
taneous discontinuance of the exciting cause. In the trades, the 
result of the latter can he usually demonstrated by the patient, 
who notices the difference between the condition of the skin on 
Monday morning after a Sunday's rest, and that which was dis- 
tressing on the preceding Saturday night. When practicable, 
protection during labor must be secured by the use of gloves, 
finger-cots, rubber-stalls, or bandages, neatly applied and retain- 
ing dressings to the part of the hand or foot which is the seat 
of the disease. For circumscrihed, non-discharging patches on 
the dorsum of the hand or foot, I can highly recommend the 
dressing described as employed by me in connection with eezema 
of the ^extremities. When the nature of the labor performed 
is such as to render it impossible to secure protection of the 
hand or fingers in this way, something may be accomplished in 
a few cases by directing that the hand be frequently dipped in a 
protective solution, or powdered during the hours of labor. 
Thus I have with success directed printers to dust their fingers 
with lycopodium, and those compelled to retain their hands in 
irritating solutions, to anoint these organs occasionally with an 
oily or fatty substance. Generally it may be said that an eczema 
of the hands is too frequently washed, and the ill effects of such 
practice are made evident not only in laundresses, but in mothers 
who personally attend to the dressing of young infants. The 
local applications made to each case may be those described 
above as suitable to each stage of the disease. When extensively 
involved, the hand should he carefully dressed, each linger being 
separately wrapped in soft linen rags smeared with camphorated 
or carbohzed, pure or diluted, linimentum calcis in acute cases; 
or, later, with a bismuth, zinc, or mercurial ointment. The tarry 
compounds are here very useful; and the caustics more than ever 
needful when there are fissures. Protective flexible collodion 
plays an admirable part about the nails where irritable seams 



ECZEMA. 161 

and fissures form, with overhanging fringes of torn epidermis 
and ragged scales, bordered by reddened outlines. In all pain- 
ful eczemas of this region the immersion of the entire hand and 
foot in hot water should never be forgotten, especially at night, 
the misused member being subsequently carefully dried, and 
enveloped in vaseline or oleaginous compounds, with the Lister 
protective gauze as an envelope ; or a pair of rather large, white, 
kid gloves, which have the advantage of being bleached and not 
dyed. In the daytime, the organ may be dressed to meet the 
requirements of the disease or the species of labor. 

In the matter of diagnosis, it should be remembered that an 
eczema of the hands may be induced by the Rhus toxicodendron, 
the disease being then liable to a transfer by contact from the 
hands to the face and genital or mammary region. Scabies of 
the same region is in this country much rarer than eczema digi- 
torum or eczema manuum. In scabies the vesicles are fewer, 
more isolated, more intermingled with crusts, pustules, and even 
bullae, which latter are rare in eczema. The discovery of the 
parasite and a history of contagion will aid in removing doubt. 
Abundance of pustular lesions in young subjects is, however, 
according to Hebra, most commonly produced by the acarus. 
Psoriasis of the palms and soles is always accompanied by the 
presence of patches in other parts of the body, whose typical 
characters should throw light on the local disorder. Squamous 
syphilodermata of the palms and soles occur early and late in the 
disease, and usually after a distinct history of infection. The 
lesions in syphilis are usually isolated, slightly elevated, circular 
in outline, averaging in size the dimensions of a coffee-bean, and 
surrounded by dry, adherent, dirty-white scales, beneath which 
the brown and red hue of the persistent syphiloderm can be 
discovered. Superficial circular excavations of tissue are also 
visible, with punched or ragged edges. The eruption is rarely, 
like eczema, accompanied by itching or discharge; but painful 
fissures may form. It rarely extends to the dorsum of the hand 
or foot, favorite sites of eczema manuum. 



Eczema as it Affects the Nails. 

There is nothing characteristic of the disease in its effects 
upon the nails. These horny plates participate in the diseases 
which affect their matrices, and thus exhibit nutritional changes. 
There is, therefore, no eczema of the nail proper, but only an 
eczema of the digit by which the nail is affected. In well- 
marked cases one, several, or all of the nails of either hands or feet 
may become rough, furrowed laterally and clubbed, or present 
an appearance suggestive of worm-eaten surfaces. They lose 
their uniformly smooth attachment beneath, and become tilted 
on their beds, with marked friability of their tissue. h\ such 
cases an eczematous condition of the skin at the margin may 
11 



162 DISEASES OF THE SKIN*. 

be detected, where the usual redness, infiltration, and scaling, 
with a sensation of itching, point to the nature of the trouble. 
Rarely the nails are Bhed. The most misshapen will be suc- 

C led by Bmooth and natural growths of nail substance, if the 

disease of the matrix be completely relieved. The treatment, 
therefore, is the treatment of the cutaneous disease. Care must 
be taken to exclude ringworm of the nails, which end can be 
reached by microscopically examining the scales scraped from 
the nail-surface. 

Dermatitis. 

Dermatitis is an affection of the skin characterized by the phenomena of inflam- 
mation, including heat, redness, pain, and infiltration, terminating in resolu- 
tion, suppuration or the occurrence of gangrene. 

The milder forms of dermatitis disappear without leaving 
behind them persistent lesion relics. The graver forms may 
terminate in gangrene, or produce death by shock or exhaus- 
tion. 

Inflammation of the skin as distinguished from its other dis- 
eases, is generally recognized as that idiopathic morbid state 
whose phenomena are induced by the action of certain special 
agencies, such as heat, cold, poisons and traumatism. The in- 
flammatory process may involve the superficial or deep portion 
of the integument, or may extend to the subcutaneous tissues, 
or even deeper. The symptoms vary with the nature of the 
cause, the extent and degree of its influence, and the circum- 
stances attending its operation. Hyperemia usually precedes 
and may be followed by a fluid or plastic exudate, by the pro- 
duction of one or more of the several recognized cutaneous 
lesions, by diphtheritic deposits upon the surface, or by gan- 
grene. With these there may he general symptoms of mild or 
severe grade, due to the influence excited by the local process 
upon the general economy. 

Dermatitis Calorica. 

Under this title are included those affections of the skin in- 
duced by extremes both of heat and cold. 

Unduly high temperatures produce in the skin some redness 
and a slight degree of swelling, the color not completely disap- 
pearing under pressure. If the exciting agent be withdrawn 
before further effects are induced, the color first deepens, then 
becomes paler, and in twenty-four hours the process is usually 
concluded with a very delicate and transitory resulting pig- 
mentation. 

Rays of heat and heated objects at a temperature above 125° 
to 175° F. produce immediately, or after a brief interval, vesi- 
cles or bulla?, isolated or confluent according to the severity of 



DERMATITIS. 163 

the exciting cause, seated upon a reddened skin which is usually 
intensely painful. These lesions are persistent or transitory, and 
generally rilled with a clear serum, which exudes and dries into 
crusts after rupture of the chamber in which it was imprisoned. 
At other times the serous exudation is so great that the epider- 
mis rises in broad plates, from beneath which the serum is 
exuded. This process may terminate by a free production of 
pus from the surface and gradual resolution. Adenopathy is a 
frequent concomitant symptom. In such dermatitis of exten- 
sive areas of the skin, the intensity of the process may awaken 
a violeut fever; or death may result from shock or exhaustion. 

In yet severer grades there is the production of an eschar, 
which is dry-brown, blackish, and destitute of all signs of vital- 
ity; or, as Kaposi describes it, dense, coriaceous, and as white as 
alabaster, upon which, nevertheless, some vesicles may appear, 
and by their presence suggest a false conclusion as to the vital- 
ity of the tissues upon which they rest. In from eight to ten 
days the eschar is removed by suppurative processes, and the 
scene is closed by the usual phenomena of granulation and cica- 
trization. The characteristics of the scar thus produced are, its 
great irregularitj 7 , its tendency to stellate radiation, and the 
production of ridges, folds, pockets, and bridles. 

The treatment of burns exhibiting hyperasmia of the surface 
is by the free use of dusting powders. In the cases where the 
serum is invited rapidly to the surface, with the production of 
vesicles and bullse, the latter should be gently punctured to give 
relief to the tension by the evacuation of their contents, but 
the roof-wall should be preserved, as it may subsequently form 
an attachment to the exposed derma beneath. The indica- 
tion then is to exclude the air as perfectly as possible and to 
prevent suppuration, indications admirably met by the applica- 
tion of carbolated oil and lime-water with the Lister dressing. 
Continuous immersion, in water of the temperature most agree- 
able to the patient, as practised by Hebra in cases of severe and 
extensive burning, produces speedy and certain amelioration of 
the pain, and a favorable condition of the wounds, though it 
does not avert a fatal issue in any dangerous case. 

Nitzsche 1 first disinfects the surface thoroughly with carbolic 
acid, having previously protected the blebs, after which it is 
covered with a thick varnish of linseed oil and litharge mixed 
by the aid of heat with five per cent, of salicylic acid. When 
this is dry, a second coat is applied, and the whole finally cov- 
ered with a thick layer of wadding retained in place by an 
elastic bandage exercising moderate compression. Cicatrization 
is said to progress beneath the dressing without changing the 
latter. When suppuration does occur the upper layer of the 
wadding is removed, and dried salicylic acid in powder is 

i Deutsch. Med. Zeit., 1881. 



164 DISEASES OF THE SKIN. 

sprinkled over the surface, the wadding being afterward reap- 
plied. 

In dermatitis from congelation there are also usually, in the 
milder tonus, circumscribed erythematous patches or plaques, 
generally recognized under the name of pernio, or chilblain, 
seated upon the digits, or, more rarely, upon the face, and occa- 
sioning a disagreeable sensation of heat or itching, especially 
after the chilled part has become unduly warm. An ulcerative 
form is described by authors as the result of the congelation, 
Berum exuding within bulla?, the latter rupturing and the tis- 
sues beneath degenerating. When portions of the skin com- 
pletely lose their vitality in consequence of exposure to cold, a 
still more exaggerated condition results. Larger bulla? form, 
filled with sanguinolent serum, or the skin is smooth, marbled 
with bluish lines, whitish, cold, and insensitive. Mortification 
ensues, followed by the well-known phenomena of the "line of 
demarcation," suppurative separation of the dead part, granula- 
tion, repair, and cicatrization. As the injuries induced by con- 
gelation are more frequent upon the extremities, the bones 
largely participate in the losses of tissue, especially those of the 
digits. Septicaemia and a fatal result may follow. 

Chilblains are commonly treated by stimulant applications, 
such as those containing iodine, camphor, carbolic acid, and 
balsam of Peru. Kaposi recommends: — 

R. Pulv camphors gr. x ; 50 

Cretse prseparat. §j ; 30 

01. lini f§ij; 60 1 

Balsam. Peruvian. rr^ xx ; 1] M. 

Frictions, with or without medication, are generally useful. 
The parts are to be carefully protected from pressure and undue 
friction effects. 

In cases of severe congelation the circulation is to be cautiously 
restored by friction in an apartment where the air is cool, in 
order to prevent too energetic reaction. 

Dermatitis Traumatica. 

External violence, various in character and severity, is capable 
of inducing dermatitis whose symptoms differ in degree, though 
their career is in general that described above. In this list are 
included the inflammations produced by surgical interference 
with the continuity of the integument; excoriations caused by 
scratching, by the friction of garments and other articles in- 
juriously acting upon the integument; by the various imple- 
ments handled in the trades; and by the bites and stings of 
beasts, insects, reptiles, and fishes. These injuries may be in 
the form of contusion, puncture, incision, or laceration ; and the 
consequences are declared in heat, swelling, redness, pain ; and 
in itching, burning, stinging, or pricking sensations, with sub- 



DERMATITIS. 165 

sequent production of pus, granulation, and repair; or gangrene, 

and separation of the slough ; or finally, by repair without these 
consequences. 

Dermatitis Gangrenosa. 

Idiopathic and symptomatic cases of dermatitis terminating 
in gangrene, where no history of external violence or caustic 
application has been obtained, are reported by several authors. 
In most of these, single or multiple, circumscribed, erythematous 
or hsemorrhagic maculae have been followed by superficial gan- 
grene with sloughing, the process being at times attended with 
constitutional symptoms of such gravity as to result in some in- 
stances fatally. In certain other cases the affected patches pre- 
sented at an early period the mummified and alabaster white 
aspect, noted exceptionally in dermatitis calorica. In establish- 
ing a diagnosis in such cases, care should be taken to exclude the 
forms of senile gangrene occurring in the lower extremities as 
the result of vascular calcification, when the skin and deeper tis- 
sues are alike invaded ; as also the cases of simulated eruption, 
produced by caustics upon the skin with a view to deception. 
In the latter class, a distinguishing feature of the lesions will 
be their occurrence chiefly upon those parts of the body most 
accessible to the hands ; and, in persons not ambidextrous, upon 
those parts which the hand predominantly employed can most 
readily reach. 

Dermatitis Venenata. 

Certain medicinal and other substances applied to the external 
surface of the skin, are capable of exciting inflammation either 
by operating as caustic, irritant, toxic, or even traumatic agents. 
In this list are included most of the strong acids and alkalies; 
croton oil; cantharides; mustard; tartar emetic; the com- 
pounds of mercury ; arnica ; turpentine; ether; chloroform; the 
tarry compounds; many of the dyes; several members of the 
rhus family (the Rhus toxicodendron and Rhus venenata, poison ivy, 
poison oak); the nettle; the smart weed {Polygonum punctatum); 
cowhnge (Mucuna pruriens) and glass in fine powder or delicate 
■filaments such as are thrust into the skin when handling certain 
articles of Venetian glass-ware. The list might be indefinitely 
extended, as there are few articles which are not capable of pro- 
ducing some irritation of the surface of the skin, if applied to it 
with sufficient vigor and for a certain period of time; and in 
some it is difficult to decide whether the effect is more traumatic 
or toxic. An almost equally long list of substances of animal 
origin might be also named having poisonous effects upon the 
integument, such as decomposed or ammoniacal urine, feces, 
ichorous pus, pathologically altered secretions from the uterus, 
eye, ear, nose, etc. 



16'") DISEASES OF THE SKIN. 

The symptoms of dermatitis venenata are substantially such 
as have been already described. Numerous types of cutaneous 
lesions, maculae, pustules, papules, vesicles, bullae, wheal-. Bcales, 
crusts, free serous and purulent discharges, subcutaneous ab- 
3,and cv.-n gangrene with sloughing, may result from the 
operation of Buch causes, the result being largely proportioned 
to the character of the agent producing the injury. 

A few of the more common sources of such accidents may he 
briefly considered. 

The use of soap for laundry, toilet, or other domestic purposes, 
containing an excess of alkali, or even minute particles of bone, 
is a frequent source of trouble, as are also several of the proprie- 
tary articles sold in the shops for similar employment. In these 
instances, the erythema, vesiculation, infiltration, or other symp- 
toms, will naturally he distinguished on the hands, or the hands 
and the face. Stockings and other undergarments dyed with 
aniline, the leather lining of the inside of the hat or the cap, 
and the painted toys to which the lips of children are applied, 
will beget mischief in the various regions of contact, for each. 
Duhring reports cases where the dye-stuff in the lining of shoes 
has penetrated the material of the stockings in women, and pro- 
duced dermatitis of the feet or legs. The tincture of arnica, an 
article unfortunately much used as a domestic application for 
contused and incised wounds of a simple character, has produced 
very serious annoyance in some cases, two such having been re- 
cently presented at my clinic in this citj\ 

An exceedingly common source of such dermatitis is urine 
retained upon underclothing in adults. A persistent dermatitis 
of the scrotum, perineum or inner faces of the thighs in either 
sex, always calls for a careful examination as to whether a few 
drops of urine are left in contact with such underclothing after 
each act of micturition. Fistula?, urinary incontinence, prostatic 
disease, "stammering of the bladder," imperfect finish of the 
coup de piston in males, especially after a gonorrhoea, and similar 
troubles, are all to be remembered. 

The eruption produced by the poison ivy and other varieties 
of rhus, is almost exclusively an American disease ; and from 
its frequency in this country has attracted a great deal of atten- 
tion. A certain degree of susceptibility to the poisonous action 
of the plant is requisite for the production of its effects, as some 
individuals can handle the leaves of the plant with impunity, and 
others are said to he affected by its exhalations within a circle hav- 
ing a radius of several feet. I have, however, never been ahle to 
demonstrate the truth of the last statement, suspecting, as I do, 
that such instances are usually cases of contact with other than 
the suspected plant. The parts commonly affected are the hands 
and the regions to which the latter are carried, such as the face, 
genitals, arms, thighs, and neck. Barefooted children suffer in 
the feet and legs. Usually the symptoms are developed in the 



DERMATITIS. 167 

course of a few hours, and consist of erythematous patches, 
scanty or profuse vesieulation with abundant, serous weeping 
after rupture of the lesions, swelling, oedema, disfigurement, and 
intense burning and itching sensations. Serious effects are occa- 
sionally produced. I have seen deeply attached scars result from 
subcutaneous abscesses of parts greatly swollen. Occasionally, 
in particularly sensitive skins, the eruption spreads from the 
surface affected by the poison, to that where presumably none 
has been applied. It should be remembered, however, that arti- 
cles of clothing may, for brief periods of time certainly, furnish 
sources of further trouble, being worn at the moment of contact 
with the plant, then laid aside, and, the occasion being forgotten, 
being subsequently employed. Thus I have known a pair of 
undressed kid gloves to reawaken the disease after lying for two 
weeks untouched. 

Careful observation of a typical case, soon after the onset of 
sj-niptoms, will disclose the exact surface of contact, each being 
delicately outlined by a reddened, tolerably well-defined line, 
within whose limitations will be seen a slightly tumefied, ery- 
thematous surface, at times displaying closely packed, pin-point- 
sized papules, which may be embryonic vesicles, or may proceed 
to resolution without serous suffusion. 

The diagnosis of the eruption will be aided by recalling the 
features described in a careful monograph on the subject by Dr. 
White, of Boston. 1 According to this author, the lateral surfaces 
of the digits first exhibit the symptoms of the eruption ; later, 
the dorsal surfaces ; and latest, the thickened palms. The efflores- 
cence also is more irregularly distributed, more uniformly vesic- 
ular, and the vesicles less transparent than in eczema. These 
lesions are, moreover, more vesicular, and less papular at the 
onset ; and, though suggesting papules by their situation in the 
palm, are in that situation readily made to exude serum by 
puncture with a needle. 

Internal medication is not required. The local treatment is 
that of eczema. The application of an alkali for the purpose 
of neutralizing the poisonous volatile alkaloid in the leaves of 
the plant (toxicodendric acid, Maisch) should evidently be con- 
sidered solely with a view to prophylaxis, as it is difficult to 
understand how such neutralization could control the inflam- 
matory process after its inception. The black wash, solution of 
sugar of lead, or oleated lime-water, should be employed at first, 
and be followed later by the dusting-powders. The late Prof. 
Babcock, of this city, a frequent sufferer from the disease during 
his extended botanical excursions, first taught me the value of 
an ointment made by incorporating a decoction of the inner 
bark of the American spice-bush [Benzoin odoriferum) with cold 

1 New York, D. Appleton & Co., 1873, from tlie March number of the New 
York Medical Journal of the same year. 



168 DISEASES OF THE SKIX. 

cream. Tt certainly has afforded very prompt relief in the cases 
in which T have been able to employ if, the difficulty lying in 
securing the hark of the shrub in its young and tender state. 

Dermatitis Medicamentosa. 

The importance of recognizing the fact, that a given eruption 
is produced by an ingested drug, can scarcely he overestimated 
from the standpoint of the diagnostician. The errors committed 
in this connection are so frequent and so annoying to the patient 
that it is necessary for the physician to inquire very carefully, 
before treating any cutaneous disease, as to the medicaments 
previously swallowed by the patient; and also to he prompt to 
connect any aggravation of a cutaneous disease with remedies 
ordered by himself for internal use. The following is but an 
imperfect list of the drugs whose internal administration may 
be followed by an exanthetn ; imperfect, because without ques- 
tion many have yet to be recognized as possessing such an 
action. As to the modus operandi of such medicinal agents, for 
the most part our knowledge on the subject is purely conjectural. 
Some, for example the iodide of potassium, are eliminated in 
part by the glands of the skin, and presumably have thus a 
local effect upon such emunctories ; others, and in this class I 
believe should be included quinia, induce an urticaria scarcely 
distinguishable from an urticaria ab ivgestis. Some, possibly, 
operate in either or both ways at different times or in dif- 
ferent individuals. The absurdity of supposing that anj* dis- 
ease can be "driven out" by the ingestion of such drugs, should 
be relegated to the specious ignorance which first framed such 
an hypothesis. 

Aconite. — This drug is said to be productive at certain times 
of marked diaphoresis with the occurrence of vesiculation and 
considerable itching. If so, it is possible that the diaphoresis 
in an irritable skin may be responsible for the trouble. 

Arsenic. — Erythematous, vesicular, papular, and much more 
rarely pustular, bullous, and ulcerative lesions, occur upon the 
face, back, and hands, after the ingestion of arsenic. The well- 
known results of the administration of the drug in toxic doses 
upon the mucous membranes of the eyes, nose and mouth need 
not be described in this connection ; nor yet the grave, gan- 
grenous symptoms, with osseous necrosis, which have been 
observed in the workers with the metal. 

I have seen a bright red, scarlatiniform blush with few iso- 
lated vesicles cover both shoulders of a young woman with a 
delicate skin after taking three medicinal doses of Fowler's solu- 
tion, the eruption being present, but less distinct upon the face 
and hands. In two cases I have seen the rash in polymorphic 
type limited to the hands alone. 



DERMATITIS. 169 

By far the largest number of such rashes are, however, pro- 
duced in those previously suffering from cutaneous disease, for 
whose relief the drug is administered. Here the toxic effect is 
declared either by — first, increased hyperemia of the skin visible 
in an erythematous patch, or beneath the scales of a squamous 
patch; or, as an areola of bright-red hue about any aggrega 
tions of lesions; second, by simple aggravation of the type of 
a disease already in existence (recurrence of acuity in a subacute 
eczema) ; third, by rapid peripheral extension of a disease which 
had previously been well limited in contour; fourth, by con- 
verting a disease exhibiting uniformity of lesion into one charac- 
terized by multiformity. Each of these results might be illus- 
trated by cases. 

In a series of eight cases of poisonous effects produced by 
arsenical paper hangings, and reported by Dr. F. H. Brown, 1 
there were, curiously, no cutaneous symptoms. 

Belladonna, Atropia. — The well-known erythematous, scar- 
latiniform, or reddish efflorescence produced by belladonna and 
its alkaloids, is usually limited to the upper segment of the 
body, but may become generalized. It is said to occur more 
frequently in children, probably because it has been adminis- 
tered largely to individuals of that age under the superstition 
that it was useful as a prophylactic in scarlatina. Very disa- 
greeable and even dangerous results have followed the instilla- 
tion into the eye of atropia as a mydriatic, the rash being 
accompanied by constitutional symptoms. 

Boracic Acid. — Modadewkow reports a case in which the 
pleura was washed out with a five per cent, solution of boracic 
acid, a part of which was not removed. There occurred as a 
result an erythematous rash over the face, trunk, and extremi- 
ties. 

Bromine and its Compounds. — A full and valuable account of 
the cutaneous effects of this drug and its compounds, when ad- 
ministered internally, is contained in a paper on medicinal erup- 
tions, read by Dr. Arthur Van Harlingen, of Philadelphia, before 
the American Dermatological Association in 1880. Acneiform 
lesions, pustules, macules, maculo-papules, papules, eczema-form 
moist patches, furuncles, urticarial wheals, scales, and ulcers 
have been induced by swallowing the bromides of potassium, 
sodium, ammonium, and lithium. By far the most common are 
the acneiform and pustular lesions, occasionally accompanied by 
pruritus, which appear upon the face and upper portion of the 
trunk, though I have seen the rash very distinctly upon the 
genital region. Duhring reports an interesting observation of 

1 Paper read before the Boston Society for Medical Observation, March 6, 1876. 



170 DISEASES OF THE SKIN. 

a case in which the eruption simulated very closely the raaculo- 
papular syphiloderm, the patient having taken the remedy for 
three years. The eruption first appeared within tive or six days 
after decreasing the dose. Kaposi has observed a ease in a nine 
months old suckling, the mother having taken one hundred and 
twenty grammes of the bromide of potassium in two months, 
herself nol exhibiting traces of eruption. In one patient treated 
by myself the eruption was generalized, but in no part exagger- 
ated. It occurred in an adult male after three months' continual 
employment of large doses of the same salt. 

Mr. Browse, of Cambridge, Eng., recommends for relief of 
these symptoms the application of a solution of salicylic acid, 
one grain to the ounce of water, frequently applied on lint, 
having successfully treated in this way sores as large as the 
palm of the hand. 

Cannabis Indica. — The only instance thus far reported of an 
eruption produced by the ingestion of this drug was observed 
by myself in the case of an adult male, who was extensively 
covered with papulo- vesicular lesions after swallowing a grain 

of the extract. 1 

Chloral. — An erythematous rash is the most common of the 
eruptions produced by chloral, though wheals, red and yellowish 
papules, vesicles, pustules, and petechial blotches have been ob- 
served. It occurs upon the face, neck, trunk, and limbs, the 
latter especially on the extensor surfaces. In a man of advanced 
years, totally deaf, who had slept only under the influence of 
chloral for four years, I observed discrete scaly patches as large 
as saucers over the lower extremities, hands, and feet. 

Martinet 2 reports an erythematous and scarlatinit'orm rash, 
occasionally commingled with urticarial and purpuric lesions, 
occurring upon the face, neck, trout of the chest, the extensor 
surfaces of the larger joints, and the dorsum of the hands and 
feet. There was no pyrexia nor indisposition, but in cases 
dyspnoea and cardiac palpitation. 

Cod Liver Oil. — According to Farquharson 3 cod-liver oil 
after being swallowed is capable of producing an acne. This 
can be true only of very inferior specimens, such as are not 
rarely found in the English market. 

Copaiba and Cubebs. — The ingestion of copaiba is occasion- 
ally followed by a vividly red rash, in the form of discrete 
macules, more rarely maculo-papules, invading chiefly the lower 
segments of the extremities and the skin of the belly, but often 

' N. Y. Med. Record. May 11, 1878. 

2 These de Paris. 1879. 

3 Brit. Med. Journ., Feb. 22, 1879. 



DERMATITIS. 171 

completely covering the surface. I have seen the rash occur in 
dark -mulberry-red petechias; and always in my experience 
accompanied by pruritus. Inasmuch as the drug is usually 
administered for the relief of a venereal disorder not syphilitic, 
care should always be taken not to confound the eruption it 
may excite with the early macular syphiloderm. Cubebs is 
much more rarely followed by a similar result. 

Cundurango. — Guntz 1 reports the occurrence of furuneular 
and acneiform lesions in twenty patients out of one thousand 
who were taking cundurango for the relief of syphilis. 

Digitalis. — In Behrend's treatise on diseases of the skin 2 ref- 
erence is made to cases where macular and maculo-papular rashes 
succeeded the ingestion of digitalis. 

Iodine and its Compounds. — Dr. Van Harlingen, in his very 
complete essay on the medicinal rashes, describes accurately the 
several lesions which iodine and its compounds are capable of 
producing in the skin. Naturally the iodide of potassium is 
responsible for the larger number of all. The frequent employ- 
ment of this drug and the very marked influence which it pos- 
sesses over the skin, render the study of these morbid results 
important. Unlike many of the other substances in the list, 
the iodine compounds are followed by some species of rash in 
probably the larger number of all persons who swallow them. 

The resulting lesions may be macular, papular, vesicular, bul- 
lous, pustular, petechial, or in the form of circumscribed, subcu- 
taneous abscesses. 

The macular rash is best seen full}' developed over the upper 
extremities, in discrete erythematous patches or in a diffuse 
blush. The cases in which I have studied it, all displayed sym- 
metry. The hands were chiefly affected and suggested in ap- # 
pearance the dyed hands of the aniline worker. It is said to 
assume at times the papular type, a transformation I have not 
noticed, though I have seen coexistence of papules upon the face. 

Berenguier describes a searlatiniform rash of sudden occur- 
rence upon the surface of which were numerous minute discrete 
vesicles. Eczema-form eruptions with abundant serous exuda- 
tions are also reported. 

A number of interesting cases are on record where the admin- 
istration of the drug was followed by the production of bullae. 
Bumstead, Taylor, Duhring, Tilbury Fox, and Finny, have 
described such in adults, and I have seen two cases in children, 
one only reported. 3 Hallopeau, 4 also, reports a case in which a 
bullous eruption followed the ingestion of the iodide of potas- 

i Vierteljahrschft. f. Derm. u. Syph., 18S2. 2 Braunschweig, 1879. 

3 Arch, of Derm., Oct. 1870. « Union Med., Mar. 25, 1882. 



172 DISEASES' OF THE SKIN. 

sium. The patient died, and the author reports in full the post- 
mortem appearances. The eruption occurred chiefly about the 
head, neck, and the upper extremities. I have called attention 
to the significant rarity of vesicular and bullous lesions in ac- 
quired syphilis, and suggested that at least sonic of the cases on 
record were those of rashes induced by the remedy given for re- 
lief <»f the disease. 

The pustules induced by the administration of the iodide are 
seen chiefly upon the face, neck, trunk, and arms. They are 
usually seated upon a firm base, and may be followed by cica- 
trices. Duhring has seen an annular patch upon the forehead, 
made up of minute vesico-pustules, which eventually developed 
into a globular violaceous mass, nearly two inches in diameter. 
On several occasions I have observed large, cherry-sized, tubercu- 
lar elevations abruptly rising from the surface of the integu- 
ment and presenting a cribriform appearance where showed the 
open ducts of several suppurating follicles (chin, cheek, nose). 

The purpuric rash occurs in petechial macules, discrete and 
miliary, situated chiefly on the lower extremities. In a case 
reported by Dr. Mackenzie (quoted by Van Harlingeif) a single 
dose of two and a half grains (.166) in an infant, was followed 
by a fatal result after the petechia? appeared. 

Mercury. — The statement that mercury when ingested is ca- 
pable of producing an erythematous rash upon the surface of 
the skin, is made by several authors of reputation. In view of 
the fact that the metal has been, in its various compounds, ad- 
ministered for so long a period of time and for so many various 
diseases without the production of cutaneous symptoms, it is a 
fair hypothesis that the few reported cases are those in which 
there was coincidence rather than causation. I have had the 
opportunity of observing a large number of individuals in whom 
.the drug had been both properly and very injudiciously employed 
for long periods of time, and have not heen able in a single in- 
stance to discover any evidences upon which to base a belief in 
its power to produce a cutaneous exantbem. A similar state- 
ment was made by Dr. White, of Boston, when this subject was 
under discussion in the American Dermatol ogical Association. 
Mercurials when applied to the external surface of the body are, 
as is well known, capable of exciting, in various degrees, cuta- 
neous irritation and inflammation. 

Opium and its Alkaloids. — Erythema, wheals, and occasion- 
ally intense pruritus with oedema and subsequent desquamation, 
have followed the ingestion of opium and several of its alkaloids, 
notably morphia. In its mildest expression this cutaneous effect 
is limited to a characteristic itching about the nostrils, which 
can be perceived in a large proportion of all patients as soon as 
the general effect of the opiate becomes apparent. In several 



DERMATITIS. 173 

cases I have observed an intense and distressing general pruritus 
without efflorescence; and in some instances have been certain 
that the subseqent urticarial efflorescence was induced by the 
free diaphoresis which the medicament induced. This is a mat- 
ter of some practical moment, as the use of an anodyne for 
the purpose of procuring sleep for a patient tormented with a 
nocturnal pruritus, would seem to be occasionally indicated. 
Inasmuch as both chloral, the bromide of potassium and the 
opiates are capable of aggravating such distress, great caution 
is in such emergencies needful. In general, it may be said that 
the employment of these and similar remedies for such a pur- 
pose, should be interpreted as a confession of weakness on the 
part of the physician, who ought to be able to alleviate the 
distress of his patient by a judicious employment of topical 
remedies. 

Phosphorus. — Hasse (quoted by Van Harlingen) cites the case 
of a young girl who exhibited a pemphigoid rash after the in- 
gestion of phosphoric acid ; and, according to Farquharson, 1 phos- 
phorus itself is occasionally responsible for purpura with gastro- 
intestinal derangement and jauudice preceding a fatal issue. 

Podophyllin. — Wiuterburn 2 reports that those who work in 
resinoid podophyllin, are liable to suffer, as a consequence of 
this exposure, from a cutaneous disease of the scrotum. 

Quinine and its Alkaloids. — Morrow 3 has collected in an in- 
teresting paper, the record of over sixty cases of the quinine ex- 
anthem, and shows that its prevailing type is exantheraatous, 
the rash being of a bright vivid hue, disappearing on pressure 
and resembling scarlatina. Other lesions produced are wheals, 
papules, vesicles, petechias, hgemorrhagic purpura, bullae, and, in 
one instance, an intense localized dermatitis with commencing 
gangrene of the scrotum. In some cases the rash reappeared 
on repetition of the dose, and even after recourse to the other 
alkaloids. The subjects were mostly females. As with most 
of the other exanthern-producing drugs, small doses, where the 
idiosyncrasy existed, sufficed for the effect. I have seen the 
rash but in a single case, that of an adult male, who, after taking 
two grains of the sulphate of quinia for the first time in six 
years, exhibited an efflorescence over the entire surface of the 
body, of discrete, finger-nail-sized, salmon- and pinkish-tinted, 
scarcely elevated patches, accompanied by a moderate pruritus. 
A repetition of the dose was followed by a recurrence of the ex- 
anthem. 

In several cases desquamation is reported as resulting from 

1 Loc. cit. z Louisville Med. News, April 21, 1882. 

3 N. Y. Med. Jour., March, 1880, p. 244. 



174 DISEASES OF THE SKIN. 

the rash. As to the occurrence of the general symptoms recog- 
nized under the title of cinchonisni (tinnitus aurium, etc.), these 

may and may not accompany the lesions. Morrow makes the 
pertinent suggestion, in view of the frequent similarity of the 

rash to that exhibited in scarlatina, that many cases hitherto 
recorded as recurrent attacks of that disease and measles with 
other anomalous cutaneous eruptions, may have been instances 
of the quinine exanthem. 

Salicylic Acid and the Salicylates. — Reports of cases where 
these substances after ingestion have produced cutaneous symp- 
toms, have been made by Ileinlein, Wheeler, and Freudenberg, 
all cited by Van Ilarlingen. The symptoms were diffused red- 
ness, urticarial lesions, vesicles, pustules, petechias, and vibices, 
accompanied by intense pruritus and followed by desquamation. 

Santoxine. — A generalized eruption of urticarial lesions seated 
upon a reddened surface, and accompanied by oedema, is reported 
by Sieveking as occurring in a child to whom santonine had 
been administered as a vermifuge. 1 

Sodium Benzoate. — "Robe 2 reports two cases in which an ery- 
thematous rash, with well-defined border, accompanied by itch- 
ins: and slight desquamation, occurred during the use of the ben- 
zoate of sodium. The patients were a woman, aged thirty- 
five, and a boy with diphtheria. The eruption disappeared 
on the discontinuance of the remedy, and was made to success- 
ively appear and disappear by its alternate use and disuse. 

Sodium Biborate. — Gowers 3 reports the occurrence, especially 
on the arms, but also over the trunk and legs, of an eruption 
resembling psoriasis after the ingestion of tbe biborate of sodium. 
Some of the resulting patches were one inch and a half in 
diameter. Three cases in all are collated. In two the eruption 
faded, wheu a solution of arsenic was added to the sodium salt. 

Stramonium. — Deschamps (cited by Dub ring) reports an ery- 
thematous rash after tbe administration of the thorn-apple. 

Strychnia. — Skinner (cited by Van Ilarlingen) reports a case 
where an eruption of six weeks' duration ensued upon the ad- 
ministration of quinine and strychnia together; the former in 
the dose of one and a half grains (.10) ; the latter in the dose of 
one twenty-fourth of a grain (.0025). 

Tanacetum. — A varioliform eruption produced by the inges- 

1 British Medical Journal, February 18, 1871. 

2 Maryland Medical Journal, June 15, 1881, p. 91. 

3 Lancet, September 24, 1881. 



DERMATITIS. 175 

tion of a drachm and a half (6.) of the oil of tansy, administered 
for abortifacient purposes, is reported by Porter. 1 There were 
antecedent clonic convulsions. The result was not fatal. 

Tar and Turpentine — Erythematous, vesicular, and papular 
rashes are reported as resulting from the ingestion of these 
substances. 



The diagnosis of the various medicinal rashes described above 
does not, fortunately, demand a recognition of the essential pecu- 
liarities' impressed upon each by the exciting cause, since in 
many cases such peculiarities do not exist. The urticarias re- 
sulting from the ingestion of u head-cheese," quinine, and chloral, 
may be absolutely indistinguishable. But to establish the fact 
that a medicamentous eruption is present in any given case is 
a long step in the direction of reaching the precise cause that 
has been in that case effective. This latter must often be ob- 
tained from the lips of the patient. The medicinal rashes are 
in general remarkable for their sudden appearance, their sym- 
metry, their diffusion over large areas of the integument, the 
presence of pruritus, the absence of fever, and their existence 
alike upon exposed and protected surfaces of the skin, hinting 
thus at the action of some cause not operating externally. Ex- 
eluding syphilis and the exanthematous fevers, a generalized 
rash of sudden occurrence should always raise the suspicion of 
a dermatitis medicamentosa. Similarly in cases of pre-existing 
cutaneous disease, syphilis, eczema, or psoriasis, the sudden 
occurrence of lesions of a new type widely diffused, or of rapid 
aggravation in situ, or speedy extension as to area of those 
already in existence, should awaken suspicion, if there be fever 
of the exanthemata ; and, without a febrile process, of the medi- 
cinal rashes. Thus I have seen two patients with eczema ex- 
hibit rapid rise in temperature, and subsequently develop a gen- 
eralized variolous rash ; and it is a matter of common experience 
to examine patients on the eve of a macular syphiloderm, or 
even long past the eruptive stage of that disease, showing their 
faces, necks, and shoulders covered with an acneiform rash pro- 
duced by the potassium iodide. The practitioner cannot be too 
strongly urged to view with exceeding watchfulness the skin of 
any patient affected with either of the common disorders, 
eczema, acne, and psoriasis, when the eruption in any instance 
becomes auomalous as to type, distribution, or symptoms. An 
illustrative example has come under my observation since the 
first page of this chapter was written. A physician, on a trip 
from Colorado to Chicago, with a long standing eczema of the 
scrotum and thigh, suddenly exhibited tumefaction of both 



New England Medical Journal, October 15, 1881. 



176 DISEASES OF THE SKIN. 

hands, with Bmall-egg-sized, discrete, dull-red plaques over the 
palms and dorsum ; and in the centre of nearly all such lesions 
a Whitish, firm, elevated wheal, the whole accompanied by sevei e 
burning, tingling, and pricking sensations. He had been Bwal- 
lowing " bromidia," a proprietary preparation, containing the 
bromide of potassium, the hydrate of chloral, and cannabis 
Indica, each single drug being capable of inducing an exanthem, 
and yet he had not the slightest suspicion of the real nature of 
his symptoms, having been questioned by a brother physician, 
to whom he exhibited the hands, as to the possibility of syphilis. 

The medicamentOUS rashes, as a rule, disappear rapidly after 
the withdrawal of the exciting cause, and require no further 
management. In exceptional cases the lotions, dusting-pow- 
ders, and emollient baths, useful in corresponding phases of 
eczema, may be indicated. 

It should never be forgotten that the patient who exhibits 
such a rash is usually one who has been suffering from the real 
or fancied disease, for the relief of which the drug was swal- 
lowed ; and this condition may call for appropriate recognition. 

Herpes. 

Deriv. Gr. ??*•«», to creep. 
Herpes is an affection of the skin characterized by the occurrence of one or 
more vesicles filled with a clear serum, disposed in groups, limited to a cer- 
tain region of the body, and pursuing a definite career within a relatively 
brief period of time. 

The term herpes is unquestionably responsible for a great 
deal of the confusion which has existed with respect to cutane- 
ous disease. By the ancients it was employed, as its etymology 
suggests, to designate a disease creeping or extending gradually 
over the surface or within the substance of the skin. By seve- 
ral more modern authors the term has been employed in a 
generic sense in the futile attempt to distinguish a series of so- 
called '-herpetic diseases" and even herpetic diatheses from 
those of a different complexion. 

The significance which attaches to the word in the minds of 
the leading dermatological authorities of this day, is exceedingly 
simple, and is limited to the features conveyed in the definition 
above given. It will be seen that the description thus embodied 
is largely that of herpes zoster, an affection which is here con- 
sidered separately in consequence of its marked characteristics. 

Symptomatology. — The disease is declared by the occurrence of 
millet-seed to coffee-bean sized vesicles, single or relatively few in 
number, and in the latter case grouped, occurring as epipheno- 
mena of a general febrile process, or as symptoms of an idiopathic 
disease. The lesions are usually short lived, surviving but for 
a few days, and are tilled with a clear, serous- tiuid which may 
become lactescent. After accidental or spontaneous rupture, 



HERPES. 177 

there is left a slightly tumid, superficial excoriation, which at 
times is characterized by a circumscribed hyperemia, slight in- 
filtration, or oedema of the base and periphery. The subjective 
sensations are not usually severe, varying between moderate 
pain, itching, and heat. There is occasionally precedent chill 
and pyrexia, but no persistent lesion relics result from complete 
involution. 

Herpes Facialis. 

About the lips, mouth, and alse of the nose, rarely upon other 
portions of the face, lesions occur singly or in a single group, 
possessing the characters described above. Their frequency 
about the lips has determined the title herpes labialis, under 
which they are described by several authors. The tongue, buc- 
cal membrane, and palate may participate in the morbid pro- 
cess; and the lesions in such moist situations are represented by 
isolated or grouped, dark-grayish patches of epithelium, Avhich 
are sensitive and exfoliate. The functions of the mouth in 
articulation and mastication are thus rendered painful. The 
disease is common in acute pneumonia, malarial and enteric 
fevers. In these cases, as Kaposi has shown, the occurrence of 
the eruption by no means augurs favorably in every instance, 
as a fatal result may nevertheless follow. 

In other cases, trifling causes are sufficient to excite the pro- 
duction of the vesicles, such as a simple coryza, exposure to a 
cool draught of air, and temporary gastric disturbances. I have 
had under observation a patient who could produce the lesions 
at will by tickling the lips with a feather. There is in some 
individuals an unquestionable susceptibility to the disease. The 
disorder is always short-lived, though often recurrent; and the 
superficial crusts which terminate the process are never followed 
by scars. 

Herpes Progenitalis. 

Lesions similar to those seen about the lips occur, in the male, 
on the inner face of the prepuce, especially upon its upper limb, 
on the glans, the balano-praeputial sulcus, and the adjacent in- 
tegument; in the female, on the hood of the clitoris, the labia 
minora, the inner face of the labia majora, and adjacent surfaces 
even as far removed as the buttocks. The preference for the 
prepuce in the male has affixed the name herpes prseputialis to 
the disease as it occurs in several of the sites mentioned. 

There is usually precedent pruritus or a sensation of heat, fol- 
lowed by one or several, pin-head sized vesicles seated upon a 
tumid and hyperasmic base. Within the praeputial sac the lesion 
may either rupture at an early moment, or assume the features 
described as presented upon the mucous membrane of the mouth. 
The resulting oedema of the prepuce is often displayed in an 
12 



178 DISEASES OF THE SKIN. 

annular tumefaction encircling the glans, while the labia minora 
perceptibly project from the general vulvar plane. In these 
localities the floors of ruptured vesicles are particularly liable 
to be irritated (coitus, caustic, etc.), and then pus and even blood 
may be exuded with much angrier excoriation and resulting 
crusts of darker shade. In the course of a few days even these 
crusts fall, and the disease is at an end. Recurrence is common. 

In several cases under my observation, a first attack of herpes 
in the male resulted in an extraordinary sensitiveness of the 
balano-prseputial membrane, which persisted for more than a 
year. The patients were all middle aged men, married, and 
virgin of venereal antecedents. The membrane in question was 
tumid, tense, slightly glazed, and dark-red to dark-purple in 
hue. Upon any undue sliding of the prepuce over the glans, a 
very superficial fissure occurred, whence a drop of serum oozed. 
The membrane wa 8 so sensitive that the passage of the finger 
over it was resented, as though the conjunctiva bad been touched. 
Unusual friction by the clothing, or the use of a stimulating 
lotion, was followed by intense pain and aggravation of symp- 
toms ; and the price of coitus was a week's rest in bed. 

Naturally the diagnosis of herpes progenitalis is between 
chancroid and chancre. The latter will be manifested by its 
induration, its period of incubation, and its characteristic double 
inguinal adenopathy. The chancroid, whether in pustular form 
or inoculated abrasion, is ab origine ulcerative in tendency, capa- 
ble of auto-inoculation, and often accompanied by sympathetic, 
inflammatory, or virulent bubo of one side. Balanitis, with its 
puriform secretion and superficial patches of reddened epithe- 
lium, is readily distinguished by its symptoms, though the two 
disorders frequently coexist. 

The practitioner should never forget that the patient who 
exhibits an herpes of the genital region to-day, may have been 
inoculated at the site of these lesions which may to-morrow or 
later take on the chancrous modification. The rule to be fol- 
lowed, then, is very simple. Xo individual with a progenital 
herpes can be assured of immunity against syphilis, till the 
longest period of incubation of the syphilitic chancre has elapsed 
since the date of last suspected exposure. 

Herpes progenitalis is always, I believe, the result of naturally 
or unnaturally induced sexual erethism. I cannot recall the 
occurrence of a single case in an individual virgin of such ante- 
cedents. 

Treatment — The milder form of herpes, as it occurs about the 
lips and genitalia, requires no treatment. The lesions of the lips 
may at times need protection by flexile collodion, plaster, or 
ointments; those of the genitals, by the interposition of a pledget 
of lint or a dusting powder. As a rule, ointments are unsuited 
for the moist mucous surface of the genitals, the odorous emana- 
tions from most diseases of such parts being retained disagreeably 



HERPES. 179 

by all grease-containing compounds. Lotions answer a far bet- 
ter purpose, and these may be made stimulant with alcohol ; 
astringent with tannin, the sulphate of zinc, or the sulphate of 
copper; anodyne with opium; and deodorizing with carbolic 
acid. Prophylaxis by the local use of aromatic wine, or tannin 
and. brandy, with continence, is a matter of importance. 

Herpes Iris. 

The behavior of the lesions in herpes iris differs somewhat 
from that just described; and this has led several authors to 
consider the affection as a separate and distinct disease. As 
there is, however, some doubt respecting the question whether 
herpes iris should not be relegated to the domain of erythema 
multiforme, I have preferred to assign it a provisional position 
in this connection. 

The symptoms at the onset are the occurrence of one or several 
vesicles or vesico-papules, which pursue their usual rapid career 
in two or three days. Upon the hypersemic ring which sur- 
rounds these, a second, and even a third and fourth circlet of 
similar lesions form, each pushing the areola further to the peri- 
phery of the patch. The older are in full retrogression while 
the newer are in process of evolution ; and the red blush which 
surrounds the earlier is undergoing color-changes from vivid to 
paler hues, while the zone of the latest vesicles is assuming its 
intensest shade. The lesions are pin-head to pea-sized, rather 
persistent, firm, and terminate more often by resolution than by 
rupture and crusting. The concentric and parti-colored rings 
may make up a single patch an inch or more in diameter, or 
several such patches may form upon the surface of the integu- 
ment. In the latter case the central disk of some of the patches 
will be seen to be made of confluent lesions. The eruption is 
most commonly situated upon the extremities, especially over 
the dorsum of the hands and feet, in which situation, especially 
when symmetrically developed, it is always, according to Kaposi, 
more nearly allied to erythema multiforme. It is, however, also 
rarely seen upon the face. The subjective sensations produced 
are usually trifling. Atypical forms occur where the lesions are 
imperfectly developed from papules, and also where, in conse- 
quence of an unusual exudation of serum, bullae appear. 

The points in which herpes iris most resembles erythema mul- 
tiforme are : the variegation of the tints in the peripheral integu- 
ment(whencethe name,iris); its localization upon the extremities 
chiefly ; its occasional symmetry ; its frequency in young adults ; 
and its tendency to occur in the spring and fall of the year. Per 
contra, herpes iris differs from other forms of herpes ; in the ab- 
sence of a precedent febrile state or neuralgic pain; in its avoid- 
ance of regions near the mucous outlets of the body (preputial 
orifice, vagina, mouth); and in the behavior of the vesicular 
lesions after attaining their full development. 



180 DISEASES OF THE SKIX. 

The affection ia evidently one upon the border line between 
herpes and erythema multiforme; and might l>e properly con- 
sidered under either title. Its existence is another evidence of 
the impossibility of drawing hard and Cast lines between all the 
clinical Bymptoms presented by different diseases. 

It can scarcely be mistaken for other diseases, in consequence 
of the elegance with which its lesions are disposed. Pemphigus 
simplex and pemphigus foliaceus differ decidedly in their career, 
however much they may, at the onset of exceptional eases, pre- 
sent certain points of resemblance. 

The affection tends to spontaneous recovery, and requires no 
treatment. A dusting powder may he applied over the surface, 
if need he, to protect the lesions from accidental rupture. 

Herpes Zoster. 

Derio. Gr. %<»TTrip, a girdle ; Shingles, Lat cingulum, a girdle. 

Herpes zoster is an acute exudative affection, characterized by the occurrence 
of groups of firm and distended vesicles, preceded, accompanied, or succeeded 
by neuralgic sensations, usually mono-lateral in distribution, and followed in 
some cases by persistent cicatrices. 

Symptomatology. — The eruption is usually preceded, for a period 
lasting from a few hoars to days and even weeks, by neuralgic 

sensations of moderate or severe intensity. These sensations are 
usually limited to the area of the integument subsequently 
or coincidently displaying cutaneous lesions. The latter first 
spring from vividly tinted maculations, as minute papules which 
produce a sensation of heat, and more or less rapidly develop 
into typically perfect, isolated vesicles, varying in size from a 
rape-seed to a coffee-bean. These lesions appear in groups and 
successively, the individual members of each attaining maturity 
simultaneously in about one week, while the succession of others 
may prolong the period of efflorescence to an entire month. 

The lesions, when fully developed, exchange their earl} T limpid 
contents for those of a lactescent or puriform character. They 
project well from the widely hypersemic base from which they 
spring; are tense from complete distension ; and have no ten- 
dency to spontaneous rupture, so firm is their roof-wall. When 
abundant, they may coalesce. Involution is accomplished by 
desiccation, and the formation of yellowish-brown crusts, whose 
fall is succeeded in certain cases b}' indelible scars. 

Several variations from the type thus described require notice. 
The vesicles may be few and typical; numerous, abortive, and 
transitory; or differ in type as they may be transformed into 
veritable pustules or bullae, or become tilled with blood from 
capillary hemorrhage. In the latter event there is still further 
departure from type, in their tendency to spontaneous rupture 
and subsequent ulceration. According to Kaposi, it is in such 



HERPES ZOSTER. 181 

cases only that cicatrices form, but this statement, in view of 
many clinical observations, must be accepted with reserve. 

The anomalies of nervous significance are, extraordinary per- 
sistence of neuralgia after the involution of the cutaneous 
lesions; neuralgia of an intense and intolerable severity at any 
period of the disease; paretic and paralytic phenomena with 
resulting muscular atrophy ; or, in zoster of the head, dehiscence 
of teeth and hair. 

The vesicles of herpes zoster are always produced in the areas 
of integument supplied by sensory nerves proceeding from the 
cerebro-spi nal tract, a circumstance which explains their limita- 
tion to a single lateral half of the body. This limitation is 
rarely observed exactly at the median vertical line of the body, as 
a few lesions will usually be seen surpassing this boundary. The 
terms zoster capitis, zoster brachialis, zoster occipito-cervicalis, 
etc., are used to distinguish the special regions involved in the 
disease. 

Zoster frontalis occurs in the area supplied by one supra- 
orbital nerve, extending from the upper eyelid to the vertex, 
with lesions spread in a fan-shaped figure over one-half of the 
brow, forehead, and scalp. It may be a severe and dangerous 
manifestation of the disease, being then complicated by agoniz- 
ing neuralgia, formidable involvement of all parts of the eye 
even resulting in panophthalmia, ulcerative keratitis, pyaemia, 
meningitis, and death. I have, however, treated typical cases 
of zoster of this region where not a single untoward symptom 
occurred. 

The cheek, side of the nose, lower lid, and palate are affected 
in zoster of the superior maxillary branch of the trigeminus, 
with consequent disorders of deglutition and dental losses. 
Other areas of special involvement are: the neck, the temporal 
region, the ear, the side of the jaw, and the tongue; the back, 
the side of the neck, the lateral half of the larynx, and the 
supra-clavicular region; the nucha, shoulder, postero-internal 
face of the arm, and the upper costal region of the trunk; the 
lateral half of the trunk along the lines of the intercostal nerves ; 
the lumbo-inguinal and lumbo-femoral regions; the buttock, 
sacro-perineal, and ano-genital tracts; and the lateral half of the 
progenital area. 

Individuals are commonly subject to but one attack of herpes 
zoster in a lifetime, though, as usual in all general laws, there 
are the few exceptions which prove the rule. The same may be 
said of double attacks, those involving simultaneously the two 
lateral halves of the body. 

The scars left by zoster are characteristic. Not only are they 
limited to the seat of the original disease, but they have a pecu- 
liarly indented look as if made by a nail-sett and hammer. 
They are particularly angular in outline, and do not exhibit the 
dead-white color of many cicatrices. 



182 DISEASES OF THE SKIN. 

Etiology. — Herpes zoster occurs in both sexes, and in the young 
as well as the old, though it is very rarely seen among infants. 
It Been) a to be somewhat under the influence of the seasons, as 
cold and damp weather serves to increase its frequency in those 
susceptible to it. A large list of other depressing agencies are 
named as effective in its production; such as certain poisons 
(arsenic?); pyaemia; carcinoma; pulmonary inflammations (in- 
cluding phthisis); septicaemia; hemorrhages; traumatism; and 
malaria. Inasmuch as no one of these causes can he cited as 
certainly effective in all cases, it can merely be said that any 
influence sufficient to induce inflammation of a sensory nerve or 
its ganglion may he followed by the objective signs of the dis- 
ease. 

Pathology. — The researches of Barensprung, Raver, "Wagner, 
Charcot, Kaposi, and others have demonstrated with sufficient 
clearness that in zoster there is always, at some point in the 
corresponding nervous tract (cerebral or spinal centres, ganglia, 
or the nerves themselves), pathological changes. These are: 
enlargements, hemorrhagic effusion, separation, softening, or 
destruction of the nervous bundles, witli hyperemia, infiltra- 
tion and multiplication of the elements which surround the 
latter. 

Pig. 19. 




-f 



J 



Longitudinal section of the third spinal ganglion of the light lumbar region from a case of 
lnmbo-ingninal zosir-r. «.". ganglion, the black points correspond with pigmented ganglion 
cells, the dark linfs to engorged vessel- ; «.',.>■.,!., . fatty tis<uv surrounding (he ganglion : 6,6, 
nerve filament divided longitudinally at the points of entrance and exit, at c,c, divided per- 
pendicularly. (Alter Kaposi.) 

According to Biesiadecki and Haight the cutaneous lesions 
originate in the deeper portions of the rete, precisely as in other 
vesicular diseases. The exudate from the hypersemic corium, 
especially its papillary layer, presses upward into the rete, the 
epithelia of which are thus separated and vertically elongated. 



HERPES ZOSTER. 183 

The serous exudation finally reaches a point where the horny 
laj'er is forcibly raised from its bed to form the roof of the vesi- 
cle. The mechanical destruction of the papillary layer of the 
corium by the hemorrhagic or purulent contents of the lesions 
results in a solution of continuity, which is healed only by gran- 
ulation and the necessary formation of a cicatrix. 

Diagnosis. — The vesicles of herpes zosfer are not rarely con- 
founded with those of eczema. But the distinction between the 
two is always very readily established. In eczema, there is itch- 
ing, but no neuralgia; vesicles which tend to rupture spontane- 
ously, and never persist as in zoster; the eczematous lesions are 
also smaller, more acuminate, and rarely distinctly limited to the 
lateral half of the body. Herpes simplex is frequently recur- 
rent, herpes zoster almost never; herpes simplex is exceedingly 
liable to spread around the mucous outlets of the body, and on 
either side of the latter, while zoster only reaches such regions 
after extension from oilier parts, and is then monolateral. Its 
lesions are, moreover, never grouped in the concentric circles of 
herpes iris. 

Treatment. — The indications to be met in the local treatment 
of herpes zoster, are the protection of the vesicles from rupture, 
and the relief of pain. These ends are best accomplished by 
thickly dusting the entire surface affected, with an opiated pow- 
der, such as the Anderson powder with morphia, lycopodium 
with powdered opium, etc. Rupture of the lesions should never 
be practised. Over the whole should be gently laid a sheet of 
soft lint or antiseptic cotton, its meshes also filled with the pow- 
der, and a bandage, when practicable, smoothly bound over the 
whole. In the milder cases, nothing more than this is needed 
from first to last. In others, where the lesions have ruptured 
and their bases undergone erosive or ulcerative changes, the 
oleated lime-water with zinc oxide, belladonna and opium or 
morphia, should be applied, and covered with the Lister protec- 
tive. Carbolated and anodyne ointments may also be used, 
especially toward the latter part of the history of the case. 
Duhring speaks well of collodion with morphia, in the strength 
of ten grains (.666) to the ounce. (32.) Kaposi warns against 
the use of the diachylon ointment. Generally, it may be said 
that ointments should be the last resort. 

~Eo remedy, for internal use, is known to have the power of 
aborting or shortening an attack. Quinine is certainly indi- 
cated, and does no harm ; but I have known quinine and strych- 
nia alike in full doses prove quite inefficacious. Other remedies 
employed are, the phosphide of zinc in one-third of a grain 
(.022) doses (Thompson); arsenic, (Kaposi); and the tonics in 
general. Anodynes, orally, by hypodermic injection, or topi- 
cally are often indispensable. Inasmuch as many patients con- 
sider the attack a trivial matter, it is of some consequence 
that they be warned of the possibilities of the future, and be 



W DISEASES OF THE SKIN. 

confined to an apartment of equable temperature, where they 
arc not exposed to atmospheric changes. Tins is of special im- 
portance in all the zosters of the face. A skilled oculist should 
lie consulted in all cases involving the eye. 

Prognosis. — Zoster usually runs a benign course, but it should 
never be forgotten by the practitioner, that the prognosis may 
be in the highest degree grave. Several severe cases have oc- 
curred in this city, where the patients, after years of intense 
Buffering, have resumed the occupations of life, physical wrecks 
of their former selves, their faces indented with profound scars, 
and the vision of one eye impaired or utterly ruined. Rarely 
the termination is fatal. 



Impetigo. 

Deriv. Lat. impetere, to rush upon. 

Impetigo is an acute affection of the skin in which discrete and usually acu- 
minate vesicles, of the average size of a coffee-bean, form and rapidly till with 
pus. which being set free after rupture of the lesions, desiccates in character- 
istic crusts. 

Ilebra has distinctly stated that the pustular, cutaneous affec- 
tion described by authors under the name, impetigo, has no ex- 
istence as an independent disease. Unquestionably a long list 
of disorders hitherto described under this term have been in fact 
forms of pustular eczema; but I am totally unable to recognize 
the characteristic s} 7 mptoms of eczema in the affection now to 
be considered. I therefore, without hesitation, follow Hardy 
and Duhring in assigning to the disease a position which its 
striking individuality certainly justifies. 

Symptomatology. — The disease is sufficiently common in prac- 
tice, beini>; observed chiefly in children and young adults of both 
sexes. In such patients, one to twenty or more isolated and 
often widely separated minute vesicles, usually acuminate, ap- 
pear upon the surface either simultaneously or in rapid succes- 
sion. They are speedily transformed into pustules, so rapidly 
in fact that often the early vesicular phase is not manifest, the 
lesions showing as minute pustules from the first. When fully 
developed, they are globular, yellowish-white in color, well dis- 
tended with their puriform contents, and projected clearly from 
the surface on which they rest. They may be surrounded by 
an erythematous areola, or be simply superimposed upon an in- 
tegument of unaltered color. They may persist as such, or 
burst, and their contents dry into a yellowish crust resembling 
honey, or into brownish tinted concretions which adhere with 
firmness to the superficial and circumscribed base, where a slight 
weeping can be determined. They are much more commonly 
observed upon the face, but are recognized elsewhere, always 
sparsely upon the trunk and extremities. The eruption is never 



IMPETIGO. 185 

in any sense generalized : its characteristic features being the 
fewness of the lesions, which are scarcely ever grouped, and their 
occurrence in capriciously selected locations. The subjective 
sensations are slight, and the eruption is more picked than 
scratched. It is common in dispensary and hospital patients; 
and since these are often the victims of neglect and the subjects 
of vices of nutrition, it has been considered the appanage of 
scrofula. But the disease is also encountered in well-nourished, 
and rosy-cheeked children. In the latter, when well cared for, 
the eruption proceeds regularly to its natural resolution; while 
in the former, it is prolonged and often aggravated, thus attract- 
ing to a greater degree the attention of a physician. The pus- 
tules are never umbilicated, never followed by cicatrices, and. are 
incapable of transmitting the disease to another individual. 

Etiology. — The causes of the disease are not clearly recognized, 
but there is some reason to believe that it originates exclusively 
in local irritation. It occurs rather at the age of childhood 
than in infancy and adult life, a period when the hands are first 
brought into contact with the face ; and these are, quite sugges- 
tively, the two sites of election. The lesions are very rarely 
scratched, more often torn with the nail in picking, so that the 
crusts may be a little blood-colored. I am inclined to believe 
that the habit of picking the nose and other parts of the face 
and body with unwashed hands, is the sole source of the mis- 
chief. In later life the habit of refraining from carrying the 
hands to the face when the former are soiled, becomes instinctive. 
Before this instinct is well established, that is in childhood, the 
hands will convey to the head any particle of filth or dust with 
which they may have been brought into contact. 

Pathology. — The lesions have been examined, microscopically 
by Duhring and others, who have thus been able to establish 
clearly the purulent character of -the contained fluid. Plainly, 
each is but a distinctly circumscribed and superficial pea- to 
bean-sized abscess, the sources of the pus being the horny layer 
of the epidermis. 

Diagnosis. — In order to establish the identity of this affection, 
it is necessary to define its exact differences from eczema pustu- 
losum. These are, first, the absence of infiltration of the tissues 
affected ; second, the absence of itching; third, the failure of the 
lesions to form patches; fourth, the isolation and wide separa- 
tion, each from the other, of lesions distinctly pustular; fifth, 
the large development and rather persistent character of indi- 
vidual pustules ; sixth, after involution of the latter, the evident 
termination of the disease, which does not, as does eczema in 
many cases, progress to form a freely discharging and crusting 
surface, the pustular being but the initial stage of a distinct 
disease-process. Manifestly, however, an impetigo of the sort 
described, is not incompatible with an eczema which is often 
originated by less irritating causes. 



186 DISEASES OF THE SKIN. 

From impetigo contagiosa, the disease is distinguished chiefly 
by the absence of the evidences of contagion. From ecthyma it 
is to be differentiated by the deeper excoriation beneath the 
pustules of the latter, and their engorge I bae 

Treatment. — The individual pustules are to be opened with a 
comedo-needle; the purulent contents gently removed by wash- 
ing with tepid water and soap; and the floor smeared with any 
mild ointment, such as live grains to half a scruple (.3S-.66) of 
ammoniated mercury to the ounce (32.) of cold cream. A dust- 
in-- powder containing calomel may be substituted for the latter 
or employed afterward. The disease tends to spontaneous re- 
covery, if the lesions are not irritated. When they are situated 
within reach of the tongue, which is constantly thrust out of 
the mouth to moisten them, they may linger obstinately, and 
require protection by flexile collodion. 

Impetigo Contagiosa. 

The late lamented Dr. Tilbury Fox observed and described 
in 1862, a form of the disease now under consideration, to which 
be gave the name, impetigo contagiosa. Several authors have 
agreed with him in recognizing this as an independent affection, 
a view which I am unable to reconcile with the opinions I have 
formed, after observation of the disease in its most pronounced 
features. 

The eruption, occurring in infancy, childhood, and early adult 
lite, is often preceded by a febrile process, and appears in the 
form of rarely numerous, isolated vesicles, vesico-pustules, pus- 
tules, or bullae, usually about the face, but also on the neck, but- 
tocks, or feet. The lesions are roundish, flat, have the average 
size of a split pea, and become covered in the course of a few 
days with dry, granular, straw colored crusts, which adhere 
closely to the slightly reddened base on which they rest. Very 
superficial erosions are to be discovered beneath, which become 
rapidly recovered with epidermis. They occasionally coalesce. 
When of the dimensions of bullae, a pseudo-umbilication may 
be observed at the apex, produced solely by flaccidity of the roof- 
wall, which is never tied down as in variola. The contents of 
the lesions are inoculable and auto-inoculable, the disease thus 
spreading from one member of a family to another, and also 
from one part of the body of an individual to another. The 
mucous surfaces are said to be occasionally invaded. The sub- 
jective sensations are mild, the itching being rarely severe. The 
disease runs a tolerably definite course, being usually at end in 
a fortnight. I have seen it recur. Kaposi states that it is at 
times accompanied by submaxillary adenopathy. 

Etiology <ui<l Pathology. — Kaposi, Piffard, ami Geber have all 
described a microscopic fungus which they discovered in the crusts 
of the disease, but neither they, nor Tilbury Fox, nor observers 



IMPETIGO. 187 

who have succeeded them, have ever been able to demonstrate 
the existence of a parasite in the contents of the lesions. Plainly 
a parasitic vegetation on the exterior crust can have no etio- 
logical significance in this connection. Now it is a curious and 
very interesting fact that this eruption generally occurs during 
convalescence from a more or less actively contagious disease. 
The antecedence of some fever in many cases, is admitted by all 
observers Duhrinor, and Fox himself, have seen it follow vac- 
cinia; and the former admits that some connection between the 
two seems probable. I have seen it occur typically in four chil- 
dren, each of whom was convalescent from varicella ; and in one 
interesting case, that of a young woman convalescent from con- 
fluent variola, T observed the lesions spring from an integument 
where the pigmentation of the scars of the last-named disease 
had not begun to disappear. 

The natural conclusion seems to me irresistible. Impetigo 
contagiosa is merely an impetigo which must, first at least, occur 
in the skin of a patient who has lately suffered from a conta- 
gious disease (varicella, variola, vaccinia). The living matter 
of the pus shares, to a feeble extent, in the activity with which 
the protoplasmic elements of such a skin were recently endowed. 
Thus originated, and in this feeble degree inoculable, such a 
living pus could readily excite the protoplasm of another part 
of the body or of another individual not convalescent from a 
contagious disease, to a similar activity. Especially should this 
be demonstrable in the tender and susceptible skin of a child. 
As regards any differences which have been named above, be- 
tween the features of impetigo in its non-contagious and con- 
tagious forms, these are all non-essential, and due to the differ- 
ence in the activity of the process. The pus of the acne-pustule 
has been successfully inoculated ; and no one to-day looks for a 
parasite in the chancroid. I fully believe that all pus which is 
living is, in various degrees, contagious ; or in other words, that 
every living product of the inflammatory process is capable in 
various degrees of inciting other living matter to a similar 
activity. 

Diagnosis. — It follows from what has preceded that impetigo 
contagiosa is to be distinguished from the non-contagious form of 
the same disease, chiefly in the power displayed by the contents 
of the lesions to perpetuate the disease. The so-called "stuck- 
on" appearance of the crusts is merely due to the circumstance 
that the latter, when there is no erythematous halo about the 
vesico-pustule, or when such an areola has disappeared, rest upon 
an unaltered integument — a feature by no means characteristic 
of any single disorder. Many syphilitic crusts have a similar, 
so-called, "stuck-on" suggestiveness. Whether the contents be 
serous, lactescent, or purulent, and whether such contents be 
imprisoned in smaller or larger chambers, are questions deter- 
mined, it seems to me, solely by the activity of the process in 



188 DISEASES OF THE SKIN. 

the superficial strata of the integument where the lesions rest. 
The diagnosis from eczema has been given above. In scabies 
there is no antecedent fever, and always multiformity of lesions 
with presence of acari. Varicella is often more generalized; its 
lesions more numerous and smaller: its crusts less bulky and 
conspicuous; and its first appearance is usually upon other parts 
than the face. 

Treatment. — The lesions are to be treated precisely as are those 
of impetigo. 

Ecthyma. 

Deriv. Gr. ex9uu*, a pustule. 

Ecthyma is a cutaneous disease manifested in the formation of few or many iso- 
lated pustules, the result of an inflammatory process sufficiently severe to 
destroy some of the elements of the derma, and to result in the production of 
a scar. 

Symptomatology. — Attention has already been directed to the 
views of Hebra in denying the existence of impetigo and ecthyma 
as distinct diseases. Ecthyma is, however, entitled to separate 
consideration, for the clinical reasons whose importance should 
appear after a careful study of a few typical cases. 

The disease is characterized by the occurrence of one or seve- 
ral, roundish, bean- to filbert-sized, yellowish or reddish pustules, 
which are the result of a distinctly circumscribed, inflammatory 
process, limited to the base of each lesion, or extending from it 
peripherally in a diminishing hypersemia. The process is dis- 
tinguished by the formation of an indurated phlegmon at the 
base of the pustule, which is converted into a loss of tissue in- 
volving the corium. The purulent contents of the lesions dry 
in dark-colored crusts, the color being somewhat dependent upon 
the quantity of the blood with which they are commingled. On 
the removal of this concretion, a minute, shallow and circular 
pit is discovered, invading the true skin to various depths, and 
lined with a tenacious, puriform, and often blood-stained pro- 
duct. When carefully wiped (dean, this solution of continuity. 
which really constitutes a minute ulcer, is seen to have a floor 
reddish or grayish in color, and indolently granulating. 

The pustules may he acutely or indolently developed, and he, 
when multiple, coincident or successive. They occasion rather 
a sensation of heat, burning, and pain than of itching, the latter 
being usually more distinct when the lesions are healing under 
their crusts. Their formation may be preceded by mild general 
pyrexia. They occur at all ages and in both sexes, usually upon 
the extremities, but also upon every portion of the body. 

Etiology. — The causes of the disease are practically those of 
eczema and dermatitis (traumatism, heat, scratching, parasites, 
etc.), but these usually operate in excess, or in subjects affected 
with other diseases, such as anaemia, asthenia, struma, variola- 



ECTHYMA. 189 

convalescence, and menstrual disorders. Filth and neglect are 
most common aggravations; in other words, that circumscribed 
cutaneous ulcer will be the angrier and the deeper, which occurs 
in the victim of any depressing disease, whose skin is scratched 
with nails begrimed with dirt, and is covered with the effete 
products of the excretory processes. The pus thus produced is 
in various degrees inoculable and auto-inoculable, as is the pro- 
duct of every inflammatory process of similar grade. 

Pathology. — The pustule of ecthyma differs in no respect patho- 
logically from the pustule of eczema or the pustule of impetigo, 
save in the severity of the exudative process by which it is pro- 
duced, and in its limitation to the exact site of external irrita- 
tion. By the extension of that process to the corium there is 
an actual loss of some of the elements constituting the papillary 
layer; and the result is a cicatrix which contracts as it grows 
older; and is, in milder cases, finally barely visible as a minute 
cicatriform punctum. One who frequently examines the skin of 
the entire body with care, can usually detect the ancient sites of 
these lesions by their indelible though insignificant relics. 

Diagnosis. — Ecthyma is liable to be confounded with the other 
pustule-producing exudative affections, but as the distinction 
between them is largely artificial, and based upon the severity 
of the inflammatory process, there is small danger in the conse- 
quence. Kaposi well expresses the truth in his suggestion, that 
there can be but little objection to the employment of the term 
ecthyma when it is desired to characterize precisely the pustular 
grade of any cutaneous inflammation at a given time. The pus- 
tules of variola are "ecthy ma-form," and many of those seen in 
syphilis possess similar characters. But in each the history of 
the general affection should throw light upon the identity of the 
cutaneous disease. In the latter, moreover, the ulceration at 
the base of the lesion exhibits the pronounced features of the 
syphilitic ulcer in its secretion, floor, edges, base, crust, and 
career. 

Treatment. — The general treatment of patients affected with 
ecthyma is a matter of some importance. A proper regulation 
of the food and hygienic surroundings is not to be neglected. 
Tonics are frequently indispensable. The destruction of any 
pediculi, and the cleansing of the skin by soap and water will 
often be sufficient to effect a great change. This is well illus- 
trated in hospital practice, where the little patients rapidly im- 
prove atter a hath, followed by inunction with vaseline, and a 
few substantial meals of a nutritious character. When the 
lesions are abundant the treatment is in general that of pustular 
eczema. Crusts are to be removed after soakings with oil or 
fat; and the floors of the former pustules, after washing with 
carbolated water, should be dressed with an ointment containing 
ten to fifteen grains (.666—1.) of the ammonio-chloride of mercury 
to the ounce (32.) of lard. If the minute basal ulcers are slug- 



190 DISEASES OF THE SKIN T . 

gisb, ;i small quantity of calomel may be dusted over each, after 
it baa been cleansed of its Becretion. Often it answers well to 
touch each separately with a small pledget of lint dipped in the 
compound tincture of benzoin, or the iodized phenol, of which 
the formula has been already given. 

Prognosis. — With proper care recovery is always, prompt. 

Furunculosis. 

Deriv. Lat. furttnculus, a petty knave. 

Furunc.ilosis is a disease characterized by the occurrence of one or more cir- 
cumscribed, cutaneous or subcutaneous abscesses, which usually terminate by 
necrosis of tissue in the centre of the phlegmon, its expulsion in the form of 
pus or a core, and a resulting cicatrix. 

Symptomatology. — Furuncles, or boils, commonly begin as both 
tender and painful indurations in the skin or it- subjacent tis- 
sues, the summit of which soon becomes visible in the epidermis 
as a reddish punctum. It is the result of an active inflammatory 
process limited toadefinite area, and of greatest intensity at the 
centre of the involved mass. More or less rapidly thereafter these 
symptoms are succeeded by increased redness, heat, and tume- 
faction, the latter producing a nut- or egg-sized tuberosity, well 
projected from the surface, or fairly imbedded within or beneath 
the derma. A yellowish point in the centre of the erythema- 
ton- swelling soon announces the occurrence of suppuration. 
When accidentally or artificially opened at this summit, exit is 
given to a thick yellowish pus which may be commingled with 
blood from the traumatism of the neighboring capillaries. The 
small ahscess may then, after discharging its purulent contents 
for a few days, gradually close by granulation, or may also expel 
from its cavity a tenacious, pus-covered, yellowish-green slough, 
known as the "core." This evacuation is usually followed by 
relief of the tense and throbbing pain which is the well-known 
subjective characteristic of the furuncle. 

The length of time requisite for the completion of this process 
varies with the extent of tissue involved, from a W-w (lays to 
several weeks. Boils may occur in any part of the body, but, 
are most common about the face, the auricular region, the neck, 
the arm pits, the ano-genital region, the hips, the buttocks, the 
breast, and the extremities. They may occur as single or mul- 
tiple lesions, or may succeed each other in crops, especially about 
the buttocks, trunk, and thighs, for a period of several months. 
It is tlii- succession of boils to which the term furunculosis is 
specially applied. The disease of the skin, in such cases, may 
produce a constitutional effect manifested in pyrexia. This is 
usually encountered when the furuncles are few and short-lived, 
only in individuals of irritable. constitutions. There is also a 
decided chloro-aiaemia due to the pain, fever, purulent drain, 



FURUNCULOSIS. 191 

derangement of the nervous centres, inappetence, and consequent 
perversion of nutrition. 

The sequelae of boils are macnlations of a violaceous tint often 
perceptible in the skin for weeks and even months after their 
disappearance; and cicatrices, pin-bead to coin-sized, which are 
permanent. 

Etiology. — The causes of furunculosis, as also of a single furun- 
cle, are often exceedingly obscure ; and it must be admitted that 
the subject requires more extended study. It is true that both 
conditions are encountered in typical subjects of u hospitalism," 
where anaemia, asthenia, marasmus, malnutrition, and exhaus- 
tion resulting from excesses, from grave general disease, from 
low fevers, and from nervous strain, play a prominent part. But 
the reverse is also true. I have recently, for example, had under 
my care a gentleman of superb physique, active habits of life, 
and large wealth, who placed at his disposal all the resources of 
medical skill, and who had yet suffered for six months from a 
persistent furunculosis. Few actively engaged practitioners 
have failed to see similar cases. 

On the other hand, scratching; eczema, scabies, and other 
cutaneous diseases ; lice and external irritants of various sorts are 
responsible for many boils, especially those that are few and not 
followed by similar lesions. When, however, such sequence 
occurs, it should never be forgotten that the furuncles, if suffi- 
ciently numerous and large, are amply capable of profoundly 
disturbing the general economy. The collar button at the back 
of the heck; the edges of an unyielding corset; for one unac- 
customed to it, a hard bench ; the saddle-tree and many similar 
articles, may be the exciting causes of furuncles. 

Lastly, it is exceedingly common for patients thus affected to 
apply to practitioners for remedies intended to "purify the 
blood;" and, inasmuch as the iodide of potassium is often mis- 
chievously prescribed in response to this demand, the original 
trouble is thus enhanced to a manifold extent. Many cases of 
furunculosis are instances of boils resulting originally from ex- 
ternal irritation, which have greatly multiplied and finally pro- 
foundly affected the system under the impulse of the so-called 
" blood-purifying" process. 

Pathology. — Authors have attempted to explain the phenom- 
ena of furuncle by supposing the process to be due to inflamma- 
tion attacking a sebaceous follicle in the derma; or a pilary fol- 
licle, or sweat-gland beneath the latter; or the peri-follicular 
tissues; or the connective tissue pedicle which passes downward 
from the fundus of the hair-follicle to the subcutaneous tissue; 
or the blood and lymphatic vessels which surround the latter. 
It is reasonable to suppose that they are all in the right. ]STo 
one of these component parts of the skin is known to be exempt 
from the changes which are induced by the inflammatory pro- 
cess. It is difficult to discover in the. furuncular lesions any 



192 DISEASES OF THE SKIN. 

symptoms which set if apart from the other results of localized 
inflammation, its phenomena differing from those of ecthyma, 
acne, pustular eczema, anthrax, etc., only by the scat and extent 
of the inflammation. The core of the furuncle represents a 
necrosis induced by the violence of the exudation, and so does 
the gangrenous Blough which falls after a severe dermatitis 
caloriea. The core of the furuncle is moist, yellowish, and 
puriform, because it is completely immeshed beneath the epi- 
dermis, an 1 pus soaked. The core or slough of a gangrenous 
dermatitis may be as dry as a crust, from desiccation in conse- 
quence of exposure to the air, or he in various degrees moistened 
by the fluids escaping from the tissues beneath. Where there 
is no core in furunculus this absence is probably due to the fact 
that the purulent products of the inflammation pass with readi- 
ness from the peripheral to the central parts of the phlegmon, 
without having to leak through or between, or to he pressed 
against, masses of centrally disposed elements, whose vitality is 
tli us the more readily lost. Inflammation of tissue in a practi- 
cally closed chamber, under tense pressure, under slight pressure, 
exposed freely to the air, or in all grades protected from it, will 
always differ in its phenomena, "it is wiser to attribute these 
differences to the circumstances under which it is displayed, 
than to any peculiarities in the nature of the process itself.' 

Diagnosis. — Boils are to be distinguished from carbuncles by 
the exaggerated symptoms of the latter, described below. Cir- 
cumscribed furuncular abscesses of the groins and axilla? are not 
to be confounded with suppurating, sympathetic or virulent 
buboes of these regions, associated with genital or extra-genital, 
contagious, venereal sores. This goes without saying; but many 
such errors have been made. Furuncles of the anal and genital 
region may be significant of surgical affections of the neighbor- 
ing parts (perineal, peri-prostatic, peri-urethral, and scrotal ab- 
3e8 of the male; suppuration of the vulvo-vaginal gland of 
the female, etc.). 

Treatment. — The debilitated constitution of many patients 
affected with boils indicates clearly the need of a tonic regimen, 
including the administration of iron, quinine, and strychnine, 
the mineral acids, and, cont rary to the generally accepted opinion 
of the laity, a generous diet of milk, cream, eggs, and fresh 
me ;i ts. To these, wines and malt liquors may be at times added 
with advantage. Change of climate, of diet, of cooks, and of 
the habits of life, is most serviceable in cases of prolonged furun- 
culosis. I have found the use of the mineral waters, at some 
of our health resorts, especially valuable for the debility which 
often results from these disorders. Other internal remedies 
which possess reputation in this complaint are arsenic, sulphur, 
and the sodic sulphites, the alkalies, tar, phosphorus, and the 
sulphide of calcium. I can speak with favor of the two last 
named only. In a few cases it has seemed to me that some of 



ANTHRAX. 193 

the elegant preparations of phosphorus, in the English and Ame- 
rican markets, have worked a decided change in the tendency to 
frequent recurrences of the affection ; and that the sulphide of 
calcium, given in eighth of a grain doses, had a similar effect. 
I am equally persuaded, however, that no one of these articles 
may be described as an efficient and certain remedy for the com- 
plaint; and that many cases will progress without hindrance 
from any or all of them. 

Attempts in the direction of aborting a furuncle may occa- 
sionally be made by the topical applications of the stronger 
alkalies (aqua ammonias) or acids; caustics or cautery; ice; or 
premature complete incision with the scalpel. These measures 
will occasionally succeed ; more often they fail. Frequent re- 
newal of hot poultices of slippery elm or flaxseed, to which an 
opiate may be added for the relief of the acute pain, should be 
practised till suppuration is established, and exit given to the 
pus or core. For a brief time afterward, they may be continued. 
(Subsequently the treatment is by carbolated lotions and simple 
ointments. 

Prognosis. — The future of the patient affected with a pro- 
longed furunculosis is that only of which there can be question. 
Eventually the worst cases are relieved when unaccompanied by 
systemic or visceral disorders, and where the circumstances of 
the sufferer permit him to pursue the most advantageous course 
(travel, diet, abstraction from business, etc.). 

Anthrax. 

Derw. Gr. a.<Apa%, a live coal. 

Anthrax is a circumscribed, cutaneous and subcutaneous abscess, usually larger 
than a furuncle, characterized by dense induration and sloughing, and termi- 
nating, in favorable cases, by the production of a persistent cicatrix. 

The term anthrax is employed by several foreign authors to 
designate the disease known among the English as murrain, 
splenic fever, or malignant pustule, the charbon of the French. 
It is here employed solely in the description of the carbuncle. 

Symptomatology. — Carbuncles are often preceded by malaise, 
chill, and pyrexia of severe grades. In cases where the anthrax 
is formidable and seated upon or near the head, alarming symp- 
toms of prostration, stupor, somnolence, and even coma, may be 
noted. With and without these concomitants, a dense, dull-red, 
indurated and painful phlegmon soon appears, varying in size 
from a small hen's egg to an orange, and even much larger, in- 
volving not only the skin but the tissues beneath. Suppuration 
finally occurs; but the pus is not confined to a single sac. It un- 
dermines the integument, and often, through several apertures, 
leaks out indolently to the free surface. The fenestrated or 
cribriform appearance of the skin covering the carbuncle,, con- 
13 



194 DISEASES OF THE SKIN. 

Btitutes, in this stage, one of its most striking features. Through 
these apertures may be distinguished the whitish or yellowish 
pus-soaked sloughs or portions of a single slough, which can be 
rarely extracted through the orifice. Often the entire mass 
separates in a single slough, involving the skin and subcuta- 
neous tissues, leaving a crateriform ulcer of formidable 
which, in favorable cases, proceeds to heal by granulation. The 
resulting cicatrix is at first of a deep violaceous tint, and later 
becomes blanched. It is indelible. 

Pyaemia and septicaemia are the commonest complications 
of anthrax. Of such a nature are the systemic phenomena by 
which it is ushered in, accompanied, or fatally concluded. It 
occasionally appears in an uncircurnscribed form, which is cor- 
respondingly dangerous. It is most often encountered upon the 
back of the neck, the hack of the trunk, and the lateral aspects 
of the hips and thighs. It is usually single, though occasionally 
two, or even three, of smaller dimensions, may be concurrent. 

Etiology.— Anthrax is produced by the obscure causes to which 
reference has been already made as probably effective in the 
production of boils. The two may co-exist;"or the one follow 
the other; and intermediate forms occur which might be assigned 
to either class. The disease is encountered more often in men 
than in women, and in later than in earlier life, simply because 
the tissues in its sites of preference offer in these individuals, 
and at these ages, a greater resistance to the exit of pus. 

Pathology. — The pathological anatomy of carbuncle is well 
described by Warren, 1 whose observations conclusively show 

Fig. 20. 




ii .if anthrax. Infiltrated papilla are seen at I, distended in balloon-shaped figures, be- 
tween which tin 1 nil' is compressed; at 33 and mp columns: adiposaj are seen; /, division 1 
in. -ins, the fibrous bundles resolving into protoplasm. (After Warren.) 

that the inflammatory process here is one with that soon in the 
simplest pustule. The peculiar symptoms of carbuncle are due 

1 The Pathology of Carbuncle, or Anthrax, Cambridge, 1881, p. 15. 



ANTHRAX. 



195 



solely to the formation of the phlegmon beneath the dense and 
extremely thick masses of fibrous tissue found in the back "for 
the protection of that comparative!}? defenceless portion of the 
body." The elements, multiplying with the intensity of the 



Fis. 21. 




-; £ 







Vertical section of anthrax. Dense net-work of fibrous bundles, with interspaces 
communicating and extending to subcutaneous tissue. (After Warren.) 

inflammatory process, first in the subcutaneous adipose tissue, 
pass upward along the fat columns described by Warren as co- 
lumnse acliposae, crowd these, push along their horizontal clefts 
branching from either side, infiltrate the derma, pass along the 
edges of the hair-follicles, fill the papillae till the latter "balloon" 
with pus, ooze to the surface through the cribiform apertures in 
the undermined epidermis, and soak the-bundles of fibrous tissue, 
relatively intact, which constitute the undetached mass of slough- 
ing tissue. 

It cannot be doubted that the general symptoms in anthrax, 
pyeemic, septicaemia, sympathetic, are due solely to pus imprison- 
ment. 

Diagnosis. — It follows from what has preceded that carbuncle 
and furuncle differ solely in consequence of the depth of the 
starting point of the phlegmon, and the density and resisting 
power of the overlying tissue. The former is therefore flatter, 
denser, less rapidly developed, larger, less tender and more pain- 
ful, opens by many rather than one or two apertures, and is 
followed by larger sloughs, ulcers, and cicatrices, and occasion- 
ally by fatal results. 

Treatment. — Crucial and other deep incisions in the local treat- 
ment of carbuncle are certainly inferior in results to the method 
advocated by Wood 1 and Taylor, 2 which I have employed in cases 
with complete success. A saturated solution of pure carbolic 
acid is injected through the several apertures in every direction 
into the sloughing tissues by the aid of an hypodermic syringe. 



1 Toledo Medical and Surgical Journal, Dec. 1880. 

2 Austral. Medical Gazette, Dec. 1, 1881. 



196 DISEASES OF THE SKIN. 

When the orifices are not sufficiently numerous, the point of the 
needle is thrust through the thinned integument at the summit 
of the swelling in several points. The pain is severe, but short- 
lived: the tissues are blanched, indurated, and destroyed; the 
Blough is in a few days readily separated after division of its 
Blender fibrous attachments; and the ulcer rapidly contracts 
with the sequel of a smaller scar. It is necessary to use pure 
acid in saturated solution to prevent absorption of the injected 
fluid and resulting toxic effects. 

Relief is afforded in many cases by opiated hot cataplasms and 
fomentations, with the requisite skill in the surgical dressing of 
the parts by carbolated lotions, extraction of the slough wholly 
or in portions by the forceps, and the subsequent employment of 
Bimple or carbolated unguents during the reparative process. 
An excellent method of withdrawing the purulent and slough- 
ing contents of the carbuncle is to apply over it, at the proper 
period, an exhausted receiver, such as a common cupping-glass. 

The constitutional treatment is that demanded in the case 
of furunculosis, including the liberal employment of tonics, a 
generous diet, a strict observance of the rules of hygiene, and 
stimulants when indicated. Pyrexic, septicemic, pyamiic, and 
adynamic states require the special management of such com- 
plications, including cold sponging of the surface in fever, and 
the use of quinine and stimulants, with artificially applied heat 
in the algid condition. 

Prognosis. — A serious issue need be anticipated only when the 
complications described- above are grave in character, or occur 
in asthenic constitutions. 

Pustules from Cadaveric Infection. — The lesions generally 
known as dissection-wounds usually occur upon the hands of 
those exposed to the dangers of post-mortem examinations and 
dissections. At the point of inoculation, which may be either 
the site of a former abrasion, rent, or the mouth of an open fol- 
licle, a painful vesico-pustule, papule, tubercle, wart, furuncle, 
or hemorrhagic bulla rises rapidly from an angry and indurated 
base, with hyperaemic areola in dull-red shades. Suppuration, 
crusting, or ulceration may follow, limited to the seat of the 
lesion; "or lymphangitis in various grades with consequent 
pysemic or Bepticsemic involvement of the system. Suppurative 
and non suppurative axillary buboes are common. Gangrene 
and necrosis of the soft parts and bones, especially the phalanges, 
may ensue, as also a fatal result from the systemic disorders 
named. In a few cases a chronic marasmus is induced. Pro- 
phylaxis, by proper protection of the hands and the immediate 
cleansing and disinfection of any accidentally wounded point, is 
of the highest importance. The treatment is to lie conducted 
in accordance with the principles already described. 



ANTHRAX. 197 

Pustules and Other Lesions resulting from Wounds In- 
flicted by Reptiles and Insects are often of an insignificant 
character. Such are the trivial results of the bites and stings 
of flies, fleas, mosquitoes, ants, bees, hornets, etc. At other 
times, however, serious and even fatal consequences have been 
recorded. The wounds produced by the tarantula and scorpion 
(which frequently lurk in the clusters of tropical fruits now im- 
ported to almost every part of this country), as also of the 
venomous reptiles, may prove to be grave. Urticarial, vesicu- 
lar, pustular, papular, bullous, and petechial lesions may thus 
originate and be the cause of a more or less severe dermatitis 
with toxic symptoms. In the latter event, it is common in this 
country to administer as remedial agents, alcoholic stimulants as 
freely as they can be ingested. 

Delhi Boil, Aleppo Evil, and Biskra Bouton. — These are 
chronic endemic disorders characterized, for the most part, by 
the occurrence of painful nodosities upon the face, hands, and 
other portions of the body. The lesions are often multiple 
papules, which subsequently become purulent and ulcerate in- 
dolently ; or become covered with scales. They are often grouped 
in patches and followed by cicatrices. The exact nature of the 
maladies thus named, is unknown. They are quite fully de- 
scribed by Fox, Farquhar, Pollack, Willemin, and other au- 
thors, as occurring in India, the region about the Euphrates 
and Tigris Rivers, and along the northern coast of Africa, espe- 
cially Algeria and Morocco. The descriptions giveu of these 
diseases certainly suggest that, in some instances at least, several 
different disorders have been included under these titles, includ- 
ing the lesions of lupus, syphilis, and the frequently formidable 
symptoms produced in the skin by the vegetable parasites in 
tropical countries. I have personally journeyed from Arabia in 
the East, along the coast to six degrees below the line in South 
Africa, and thus enjoyed a fair opportunity of observing the 
symptoms of many of the endemic disorders of that region. In 
no single instance have I been able to persuade myself that the 
numerous furuncular, papular, and pustular affections encoun- 
tered, differed from the similar lesions observed in temperate 
climates, except in that they were greatly aggravated by tilth, 
meagre diet, intense heat of climate, ignorant and vicious med- 
ication, and the syphilitic diathesis. 

Laveran 1 has lately described afresh the Biskra bouton. It oc- 
curs not only in Biskra, but also in the adjoining oasis, and is 
plainly identical with the Aleppo boil. It shows itself as an 
endemic only in the months of September and October, and con- 
tinues till December. No new cases appear in January and 
February. All ages, both sexes, the strong and weak, are liable 

1 Annal. de Derm, et de Syph. t. i., 1881, p. 173. 



108 DISEASES OF THE SKIN. 

to it. The eruption affects the face and extremities by prefer- 
ence, sometimes also the trunk. It ordinarily attacks the same 
person bul once, yet may recur. So long as thedisease prevails, 
the least excoriation lias a tendency to become Biskra button. 
At first there is a reddish, painless elevation of the skin, the 
size of a pin's head ; the centre of this soon dries, and a brownish 
crust forms, easily removable. Beneath this, there is a small 
round ulcer. The papules may occur in patches, hearing thick 
crusts which long resist. The crusts are remarkably dry. When 
the latter are removed and the ulcer left alone, a new, less firm 
crusl forms: when dressed, the crust-formation is prevented and 
an ulcer of an obstinate character remains, which in the leg is 
not unlike a varicose ulcer. If the original crusts he not dis- 
turbed, these eventually fall and leave no scar. Should, on the 
contrary, the crust he removed at the beginning ot cicatrization, 
this is accomplished slowly, and a permanent scar remains. 
Lymphangitis, erysipelas, and phlebitis, occur as complications. 
There are no peculiarities in the crusts. Epidermic cells, pus 
corpuscles, and bacteria, are commonly recognized by the micro- 
scope. An expectant treatment is the best. Should the crusts 
be removed or fall off, it is advisable to powder the ulcer with 
henna, which favors the production of fresh crusts and cicatri- 
zation. As regards its pathogenesis, the author holds Weber's 
view, that the disease is contagious and inoculable, and perhaps 
auto-inoculable. The virus exists in the crusts, but its nature 
is not established. Carter's opinion as to its parasitic nature is 
not tenable. 

Psoriasis. 

Deriv. Gr. J.a>ea, the itch. 
Psoriasis is a cutaneous disease, characterized by masses of whitish, lustrous, and 
adherent scales, exposed in pin head-sized agglomerations upon the surface of 
the skin, or in larger disks resting upon circumscribed and reddened patches 
of epidermis, which are readily made to bleed. 

Symptomatology. — The primary lesion in psoriasis is a puncti- 
form macule of reddish-brown tint, always, at the earliest moment 
of observation, covered with a delicate, whitish, epidermic scale. 
When this is removed even by gentle scraping, one or more 
minute droplets of blood exude from the points, beneath which 
lie as many vaseular papillae of the corium. When several or 
many such small points are visible upon the surface, the disease 
is called PSORIASIS PUNCTATA. 

Should the disease progress to fuller development, patches of 
larger size form, always with a definite contour, very slightly 
elevated above the general level of the integument, and covered 
with whitish, mother-of-pearl-colored scales in abundance. When 
these are about the size of drops of water, the disease is termed 
PS0RIA8IS GUTTATA. 



PSORIASIS. . 199 

In yet more advanced conditions of the disease other names 
are employed, all from the external configuration of the patches, 
none having any pathological significance. Thus psoriasis num- 
mularis is characterized by coin-sized patches; psoriasis circi- 
nata or orbicularis, by patches where the disease is actively 
exhibited at the periphery of a circle, in the centre of which the 
scales have disappeared: psoriasis gyrata and pigurata, by co- 
alescence and extension of several patches, forming thus fantas- 
tic figures covered with grayish-white, inbricated. scales; and 
psoriasis diffusa, by much more extended and uniform involve- 
ment of the skin in large areas. 

The greatest variation is exhibited in the progress of the dis- 
ease, and to this point special attention should be directed. 
Thus, in a single individual the eruption may appear upon one 
or more regions of the body in the form of the punctate lesions 
described above, and thereafter regularly progress through the 
degrees suggested by the list of names given above till the entire 
surface of the body is completely covered, from the crown of the 
head to the sole of the feet. This is fortunately rare. More 
often the eruption tends to remain stationary when one or ano- 
ther of the less extensively developed phases of the disease has 
been displayed. Thus the patches may be at no time larger 
than a silver quarter of a dollar, and though very numerous, 
fail for years to extend beyond such a limit. They may even 
persist for a longer period in even smaller dimensions, or what 
is perhaps more common, occur in guttate forms upon the chest, 
and in patches as large as the palm over the knee or sacrum. 

The sites of preference of the disease, are over the extensor 
surfaces of the extremities, especially about the elbow and knee, 
where it is decidedly most common. After these locations should 
be named in order, the region of the sacrum (where often the 
largest patch upon the body can be discovered,) the upper surface 
of the chest, the scalp, the face, the belly, and the genitals; 
more rarely the hands and feet. 

The disease is essentially chronic in its course, is never con- 
tagious, and the efflorescence does not usually awaken any sub- 
jective sensation. Its features are so pronounced in typical cases 
that its recognition is facile, by appreciating the number and 
distribution of the patches, their clean-cut outline, the unaltered 
integument between, the lustrous and shining scales, and the 
red border of the skin which ma}' crop out from beneath the 
squamous thatch above, or be completely hidden by the latter. 
Rarely a single isolated patch betrays the existence of the dis- 
order. 

When the disease is acutely spreading over the surface it has 
occasionally a different expression. This is often seen in young 
adults. The patches are perhaps as large as the section of a 
hen's egg; dark or lurid-red over the whole; covered with a 
more uniformly constituted, thin, squamous film, or sheet of 



200 DISEASES OF THE SKIX. 

semi-transparent delicate membrane, through which the red 
glare of the patch beneath is visible. T have Been this condi- 
tion also in young persons to whom arsenic had been adminis- 
tered For tlif relief of the disease, with the production of irrita- 
tive i fleets. 

In its indolent moods the color of the patch varies some- 
what with the hue of the patient'x complexion. Blonde women 
with flaxen hair and clear tint of the integument often exhibit 
singularly waxy-whitish patches, decidedly differing in color 
from those occurring upon the muddy and greasy integument 
of certain dark-skinned males. 

The scales are usually abundant, and may adhere with con- 
siderable firmness to the patch, or, more frequently, be shed 
freely from the surface, in pronounced cases powdering the cloth- 
ing of t lie patient or the sheets of the bed upon which he reposes 
at night. 

There is never at any time in the course of the disease, the 
appearance of other lesions or their sequela?, such as vesicles, 
pustules, crusts, papules, tubercles, ulcers, or any discharge fea- 
ture. The eruption is dry from first to last. Exception only 
may be made in the case of patches occurring where motion of 
the skin produces fissure, an accidental and by no means charac- 
teristic complication. The same may be said of certain acute 
symptoms, especially developed in young and tender skins, 
where considerable redness, occasionally with an erythematous 
halo, appears in and about individual patches, with the produc- 
tion of itching, heat, burning, [tain, or other disagreeable sensa- 
tions. 

The involution of the disease is evident in a gradual cessation 
of the scale-formation and the exhibition of a normal epidermis, 
which gradually spreads from the centre, or is at once perceptible 
over the entire surface of the patches. ISTo cicatrization results. 

Etiology. — The causes of psoriasis are not known. As no ex- 
ternal or internal factors can be demonstrated to be effective in 
its production, it is safest to conclude that these unrecognized 
sources of the affection are limited to the skin itself. The dis- 
ease is neither contagious, hereditary, nor limited to either sex, 
occupation, or social condition. It bears no relation whatever 
to syphilis, eczema, gout, rheumatism, struma, or dyspepsia. It 
appears in the feeble and delicate as in the most superb speci- 
mens of manly vigor and womanly beaut}'. Though not occur- 
ring in infancy, it yet usually first appears in early life. Kaposi 
reports a single ease in which the eruption appeared in the eighth 
month of lite. Under these circumstances, the question arises: 
Is this affection of the integument, when uncomplicated by the 
disagreeable symptoms named above, a disease or a deformity? 
Certainly in a very large number of individuals, displaying 
through life unchanging patches where the characteristic symp- 
toms are the same year after year, the ailment would seem to be 



PSORIASIS. 



201 



more properly classed with the deformities than with the dis- 
eases of the skin. In point of frequency the eruption ranks 
next after eczema. 

Dr. Gowers alone reports the artificial production of psoriasis 
by the internal administration of the biborate of sodium. Allu- 
sion has been heretofore made to this circumstance in the chap- 
ter on dermatitis medicamentosa (q. v.). Further evidence would 
be required to establish the fact that these results differed to 
any appreciable extent from those recognized in any squamous 
dermatitis produced by an ingested drug. 

Pathology. — The observations of Wertheim, Neumann, Aus- 
pitz, Kaposi, and Robinson, of New York, are substantially in 
accord respecting the general character of the changes occurring 
in the course of the disease, though they differ upon the question 
whether it depends upon an inflammatory or purely hyperplastic 

Fig. 22. 




Vertical section of skin from a patch of psoriasis of long- standing. MP, Malpighi 
prolongation; C, coriuni ; i, leucocytes. (After Janiieson.) 



process. So far as this problem is illuminated by clinical facts, 
it would seem clear that both views are correct, the disease being 
at times unquestionably the result of a circumscribed inflamma- 



202 DISEASES OF THE SKIX. 

tion; al others associated with a simple overgrowth of the ele- 
ment of the epidermis ; and again at times with an inflammation 
which the hyperplasia lias awakened. There is always abnndaut 
development of the epithelia in the rete. and, in recently formed 
patches, distension of the blood and lymph vessels in the papil- 
lary layer of the corium beneath. In older plaques the rete 
either dips downward to an unusual extent between the papilla, 
or the latter push upward in the manner of wart-like prolonga- 
tions. It is reasonable to conclude that at times both hypertro- 
phies concur. The corium is thickened later by an increase of 
its elements which may involve its entire width as far as the 
connective tissue. In the older plaques also the connective tis- 
sue elements are often separated by a slight serous infiltration, 
Hyper-pigmentation is also noted. The external root-sheath 
of the hairs in direct connection with the rete participates in 
the same process, thus explaining the defluvium capillitii of 
certain cases, and the resulting transient or permanent baldness. 
The sebaceous glands are secondarily involved in the scalp only. 

Lam; - , 1 of Innsbruck, has lately attracted notice by his alleged 
discovery of certain fungous elements in psoriasis, which he 
claims to be the cause of the disease. These he finds in the 
whitish pellicle beneath the superficial squamous layer, to which 
Bulkley had already culled attention. After stripping this pel- 
licle, or a part of it, from the surface, and subjecting it to the 
action of a five per cent, solution of caustic potash, the epithe- 
lium becomes translucent, and upon and beneath the latter 
double-contoured and highly refractive spores become visible to 
him. Lang considers this to be a fungus of the lowest species, 
different from any previously recognized upon the skin. He 
terms this, a epidermo-phyton " In his treatment of psoriasis 
the author proceeds upon the principles which govern the man- 
agement of the other dermato-mycoses. He considers that the 
value of the remedies hitherto found most useful in the disease, 
such as tar, carbolic acid, chrysarobin, and the mercurials, owe 
their efficacy to their destructive action upon the fungus. He 
has used with advantage a topical application of rufigallic acid 
in a salve, one part in ten. All this, of course, requires confir- 
mation. 

Diagnosis. — The recognition of a pronounced case of psoriasis 
is made with, ease, and often by those unskilled in cutaneous 
disease. As usual, it is the atypical forms of the eruption which 
occasion doubt. It is to be distinguished from 

Eczema. — Eczema and psoriasis differ in a striking manner 
with respect to their sites of predilection, and their extension 
from such sites in progressive cases. Eczema, from the head to 
the toes, elects the anterior surface of the body, the neigh bor- 

1 Volkinunn's Bammltms Klinisch. Yortr., 1881. 



PSORIASIS. 203 

hood of the mucous outlets, the flexor faces of the joints and 
limbs, the crevices, folds, pockets, depressions, and protected 
angles of the skin. Psoriasis elects the posterior surfaces of the 
body, avoids the vicinity of the mucous outlets, spreads abun- 
dantly over the extensor aspect of the joints and extremities, 
and enjoys the region of pressure and friction, as the skin over 
the patella and the olecranon process of the ulna. Psoriasis, 
covering the vertex and scalp, lingers at the brow where its 
scaly thatch stretches from side to side close to the line of the 
hairs, and creeps more indistinctly down the face on either side 
in front of the ear, reluctant to spread over the cheeks, nose, 
and lips. Eczema easily escapes from the scalp to the nose, lips, 
or chin; or lurks in the folds of the pinna of the ear. Psoriasis 
will cover the back and reach forward in front by almost sj^m- 
metrically disposed parallels in the direction of the ribs, while 
eczema sweeps between and beneath the breasts or around the 
nipple. Psoriasis will cover the belly and spare the navel and 
pubes where eczema may originate. As before stated, the larg- 
est patch of psoriasis on the body will often be discovered over 
the sacrum, while eczema creeps upward with a diminishing 
vigor from the anus between the cleft of the nates. Psoriasis 
spares the hands and feet which eczema punishes. 

In individual patches eczema will be recognized by its severer 
itching; the scratching it excites; the history of moisture, dis- 
charge and crusting; its ill-defined outline ; its asymmetrical dis- 
position, except upon the similarly irritated hands and feet ; and 
the fewer, more yellowish, smaller, and less lustrous scales which 
characterize its squamous varieties. 

Favus of the scalp might be mistaken for psoriasis of the same 
region, but the occurrence of its sulphur-colored, cup-shaped 
crusts, the existence of the parasite, the lustreless and brittle 
condition of the hairs, and a possible history of contagion, will 
insure its identification. In psoriasis, too, the hairs are usually 
firmly attached in their follicles, while they are loosened in 
favus. 

Lichen Ruber, though a very much rarer disease than psoria- 
sis, must in eases be carefully recognized as distinct from the 
latter. In it the lesions are papular, distinct, covered by few 
scales, and these yellowish in color, never lustrous. There is 
always a constitutional impairment of health, and, when the 
whole epidermis begins to break up in scales, a condition of well 
marked marasmus. When scratched, the patches of the disease 
do not bleed. Finally, lichen ruber tends to a fatal termination. 

Lupus Erythematosus. — In any doubtful case where cicatricial 
tissue is discovered in the site of a patch where the disease has 
existed, the diagnosis is clear, since psoriasis never leaves a scar. 



204 DISEASES OF THE SKIN. 

Lupus prefers the nose, the cheeks, and other parts of the face, 
commonly Bpared by psoriasis unless it he very abundant else- 
where. The lupus BCales are scanty, firmly adherent, yellowish, 
and attached to the orifices of the ducts of the sebaceous follicles; 
those of psoriasis are abundant, lustrous, and shed freely from 
the surface. Lupus is never like psoriasis, a generalized eruption. 
There is a bluish and violaceous tint to the reddish patch of 
lupus erythematosus, especially as it occurs upon the face, while 
the highly colored patches of psoriasis are rarely facial, being 
more commonly seen on the trunk and extremities, while the 
out-cropping disks on the face are the least-colored of any on the 
body. 

Seborrhea. — This disease could only be confounded with pso- 
riasis of the scalp. But in the latter ease the affection is, in the 
vast majority of cases, exhibited also in patches upon other por- 
tions of the body where seborrhcea is never seen. Seborrhoea of 
the scalp also occurs in usually diffuse forms, the surface beneath 
the crusts being rather anaemic and pallid in appearance, not 
bleeding readily, as in psoriasis. The crusts, too, in sehorrhcea, 
are distinctly fatty and greasy when rolled between the fingers, 
and have a dirty-yellowish hue, never recognized in the whitish 
scales of psoriasis. Lastly, seborrhceic crusts may fringe slightly 
the line of the hairs at the brow, hut never form a hand an inch 
or more in width, like a frontlet covering the upper half of the 
forehead, a not uncommon development in psoriasis. 



Syphilis. — Psoriasis does in many cases greatly resemble the 
squamous and papulosquamous syphilides. The necessity for a 
clear recognition of either disease occurring in suggestive patches, 
is often of the highest importance. 

In syphilis the greatest aid will he attained by a history of in- 
fection, adenopathy, mucous patches, and abortions, miscarriages, 
or still-births in the female. Psoriasis is a singularly uniform 
disease; syphilis decidedly multiform in its manifestations. The 
syphilitic patches are less symmetrical, more elevated at theedge, 
and the scales with which they are covered, fewer, smaller, and 
dirty-whitish, rather than lustrous in color. In syphilis, the 
eruption is less generalized, and shares with the other syphilo- 
dermata in the brownish and purplish hues of the skin beneath, 
lacking the vivid redness and pinkish-red of many non-syphilitic 
lesions. The scales of many of the syphilides, which resemble 
psoriasis, partake of the character of crusts, being agglutinated 
by pathological exudations from the patch; they are rarely so 
exclusively squamous as in psoriasis. In syphilis, the tendency 
of the patch is to exhibit an affected surface somewhat beyond 
the line of the scales; in psoriasis, the scales more frequently 
reach beyond the border of the affected epidermis beneath. The 
squamous sypbiloderm of the palms and soles may exist in these 



PSORIASIS. 205 

localities only. Psoriasis is extremely rare in such situations, 
and is never, I believe, limited to that region exclusively. A 
psoriasiform circlet limited to the region of the mouth, nose, or 
chin, will generally prove to be syphilitic. The disease which 
has tor a long time persisted in the production of squamous 
patches can generally be demonstrated to be psoriasis ; as syphilis 
changes its type in the course of months. 

Tinea Circinata. — Here the discovery of the parasite, the his- 
tory of contagion, and the frequent limitation of the disease to 
a single patch (a feature exceedingly rare in psoriasis), will usu- 
ally suffice to establish a diagnosis. In ringworm of the body 
the scales are bran-like, aud more abundantly formed at the 
margin of the patch where the fungus is luxuriant; while in 
psoriasis, the scaliness is usually equally pronounced over the 
entire area of an invaded patch, unless the disease is in process 
of involution. The occasional occurrence of vesicles and vesico- 
papules at the peripheral border of the patch in ringworm, is 
never observed in psoriasis. Ringworm is never generalized 
symmetrically; and upon the scalp or beard the discovery of 
brittle and broken-off hairs should always suggest examination 
for the parasite. 

Treatment. — As the cause of psoriasis is absolutely unknown, 
all treatment for the relief of the disease must necessarily be 
limited to the removal of its objective features. Tins treatment 
may be internal, with a view to the indirect action upon the 
skin, of the drug selected; or topical, with a view merely to the 
reproduction of a sound epidermis in the patches of disease. 

Without full repetition of the remarks heretofore made, rela- 
tive to the efficacy of the drugs known to have an active effect 
upon the skin after their internal administration, it is proper 
to state in this connection that arsenic enjoys the highest rank 
in the internal treatment of psoriasis. What it is capable of 
accomplishing in other cases, it can with best effect accomplish 
here. Whatever failures must be charged to its account in the 
attempt to relieve other cutaneous eruptions, cannot safely be 
ignored here. 

The facts are these: Arsenic administered internally is assur- 
edly capable of relieving a certain proportion of cases of psori- 
asis. Given improperly in any case, it may be either powerless 
or manifestly injurious. In a certain proportion of patients, 
most carefully selected as fit subjects for its therapeutic action, 
arsenic will prove utterly valueless in the most skilled hands. 
It cannot be demonstrated to possess the power to prevent recur- 
rences of the disease, and yet the latter must be recognized as 
one exceedingly liable to recur. Unfortunately the proportion 
of cases in which it will and in which it will not, exhibit its 
happiest effects, is not known. 



206 DISEASES OF THR SKIN'. 

The following rule-; for its administration are to be in general 
observed. It should be given with or immediately after the 
ingestion of food, so that it may be commingled with Bubstances 
in the Btomach. It should be given at first in small doses, which 
are to be cautiously increased. The possibility of the production 
of toxic effects should be remembered, and on the appearance of 
these the remedy is to Ik- given in a smaller dose, and not com- 
pletely discontinued unless such a course be imperative. If its 
administration is once determined upon, the arsenic should not 
In- hastily withdrawn and another remedy substituted for it, 
hut persistence for months should he enforced if no serious ob- 
jection exists, lest the time be wasted which has been already 
expended in the effort to relieve the disease. 

Arsenic is unsuited tor all cases of psoriasis occurring with 
rather acute symptoms, such as subjective sensations and unusu- 
ally vivid redness of the patches. It should not he given when 
the disease is in process of evolution, and therefore not in psori- 
asis punctata and guttata, unless the lesions have been long 
limited to patches of the sizes to which these names are given. 
For the same reasons it is often objectionable in the psoriasis of 
the young, for, though the drug is usually rather well tolerated 
in such periods of life, it is, unfortunately, in these also where 
the disease is most often encountered in its progressive stages. 

The remedial effect of arsenic, when such is obtained, seems 
to depend upon the impression it exerts upon the rete, and that 
pari of it especially which lies in connection with the derma, or 
rather with the structureless limitary membrane interposed be- 
tween the two. When the metal is injected suhcutaneously, its 
first ell'ects, according to Jamieson and Nunn, 1 are indicated by 
the appearance of a faint narrow band along the base of the 
columnar epithelia immediately next the basement membrane. 
This is due to a softening of the protoplasm which separates the 
epidermal from the dermal elements. Subsequently the remoter 
epithelia are involved, the protoplasmic threads becoming ob- 
scure, the characteristic arrangement of the epithelia less evi- 
dent, and the natural features of the rete distorted so that it 
remains attached to the derma by tags, and the prolongations 
which it sends down to the cutaneous glands. Jamieson sug- 
gests that arsenic stimulates the epithelia to exhaustion, that 
layer which lies next the bloodvessels containing the metal first 
appreciating its effects. 

The preparation usually employed is Fowler's solution, the 
most soluble of all, whose exhibition should be always begun in 
three dropdoses; this amount to be contained in a solution of fixed 
and relatively large dose, such as a teaspoonful of the infusion 
of peppermint; the wine of iron; or dilute syrup of gentian or 

1 Bee the paper by the former on the Histology of Psoriasis, Edinburgh Med- 
ical Journal, January, lbT'J, p. 027. 



PSORIASIS. 207 

of orange flowers; or the compound tincture of cardamom with 
water. When only remedial effects are obtained, such as dimi- 
nution of the scaliness, the dose may be steadily continued with- 
out change for long periods of time, and usually with advantage 
for some "time after the symptoms of the disease have entirely 
disappeared. When, without the production of toxic effects, 
the eruption seems quite unaffected by the treatment, the arsenic 
may be, very carefully and always under the direction of the 
physician only, pushed till twenty and even thirty drops of the 
Fowler's solution (the latter equivalent to one-third of a grain 
(.022) of arsenic) are administered at a dose. 

The constitution of the Asiatic pill has been given in the 
chapter on general therapeutics. The pill is less likely to be as 
well tolerated by the stomach as Fowler's solution, but cases 
are on record in which the psoriasis which proved rebellious 
under the administration of the liquor arsenicalis, Donovan's 
solution, and other internal remedies, yielded to the influence 
of the arsenious acid in pilular form. Hebra has given two 
thousand Asiatic pills to a single patient before the disease dis- 
appeared; and in no instance has he seen any ill effects pro- 
duced. 

With regard to the vulgar opinions respecting the arsenic 
habit which a long familiarity with this dosage has been sup- 
posed to beget, I consider it a curious circumstance that I have 
never yet encountered such an instance in a psoriasic subject 
who was consuming arsenic. Patients who for several consecu- 
tiveyears have,without interruption, pursued an arsenical course, 
thus barely succeeding in keeping their cutaneous ailment out 
of sight, will in many cases affirm that, apart from any trifling 
and accidental toxic symptoms, and those evident in the course 
of the eruption, they would not be sensible of the fact that they 
had taken the drug. 

Personally I may say, that with an enlarging experience, I view 
with greater distrust each year the benefits to he derived from 
arsenic in any untried case of psoriasis. The large possibilities 
of its failure, of the repeated recurrence of the eruption, of the 
necessity of continuing the medication for one or two years, and 
even after that period of time, of even then witnessing a general- 
ized development of the eruption to an extent quite equal to that 
exhibited at the outset, all these considerations should certainly 
have some weight in the mind of an ordinarily prudent man. 
'Is the ultimate result in such cases worth the cost by which it is 
obtained? In such cases certainly it would seem not. In the 
others, wdiere, under a judiciously directed arsenical course, the 
eruption slowly disappears and fails to recur, the value of the 
treatment is incontestable. As before stated, the proportion in 
which these two classes of cases are related, is not known. Per- 
sonal observation and experience lead me to believe that the 
patients in the last named category decidedly outnumber the 
others. 



203 DISEASES OF THE SKIN. 

The course which, under the circumstance, I prefer, is this: 

Instead of resorting first to the arsenical dose and afterwards to 
Other measures, the order should be reversed. That psoriasis 
which fails to respond to other treatment, may be finally sub- 
jected to the influence of arsenic, lie who having vainly tried 
other approved measures, essays at last the virtues of this medi- 
cament, ought certainly to exhibit no impatience while testing 
his case with it. He should he willing to try it fully and fairly, 
and he of all men least ready to exchange it for a less valuable 
substitute. I have purposely omitted to speak here of the effect 
of conjoined internal medication with arsenic and external treat- 
ment l>y topical applications. However desirable it may be, in 
the management of any individual case, to arrive at the desired 
end by the speediest method, it is evidently needful, in order to 
assign to arsenic its exact therapeutical value, to understand 
what it can accomplish unaided by topical measures. 

As to the other remedies employed internally for the relief of 
the malady, a very fair estimate of their value can be made by 
remembering that arsenic is superior to them all. If arsenic 
fails so frequently, what remains to be said of the other articles 
in the list? Phosphorus, copaiba, mid pilocarpine, have at times 
a feeble or transitory influence over the patches of the eruption, 
but their employment will disappoint far more often than satisfy. 
Iron, quinine, cod-liver oil, and the salts of the alkalies, will fill 
important indications in the treatment of certain classes of pa- 
tients, but these are in the minority, as the eruption is more 
often seen in perfectly vigorous and otherwise healthy subjects. 
I have been unable to discover, after the use of any one of these 
remedies, any decided effect upon the cutaneous symptoms, even 
when patients in whose case they were indicated, improved un- 
der their use. The same in general may be said of the use of 
dietary articles in psoriasis. As no ingesta save the substances 
already named are recognized as influencing the eruption to any 
perceptible degree, the diet suitable for a patient may be in brief 
described as that which is both wholesome and nutritious. 

The external or local treatment of psoriasis requires patience, 
care, and a certain degree of skill. Properly conducted, its re- 
sults are reasonably satisfactory in a large majority of cases. 

The first indication to be met is the complete removal of the 
epidermic scales from the patches, and this is accomplished in 
various ways. It is preferable to secure first their maceration 
in some fatty substance, such as one of the oils, or glycerine, or 
vaseline, after which they may be washed off by the aid of soap 
and water, in a general bath if the eruption be extensive. If it 
be localized, these oily or fatty substances may be spread upon 
pieces of lint or cotton, and thus retained by a bandage in con- 
tact with the skin. The scales may also be speedily removed 
with the dermal curette, if they occur in few patches, or if the 
latter are to be found in totality or part upon some portion of 



PSORIASIS. 209 

the body where the disfigurement demands special attention, as 
upon the forehead and. cheeks. The squamous masses are also 
removable by water alone, as after maceration of the skin in a 
bath, or after profuse diaphoresis, or even moderate exudation 
of sweat, if evaporation of the latter be prevented by covering 
the affected part with oiled silk or rubber cloth. Usually there 
is no difficulty in removing these scales, patients often remarking 
to their physicians that they can themselves cleanse the surface, 
if they can be shown how to prevent the recurrence of the des- 
quamation. 

Baths play an important part in the subsequent treatment of 
the disease. They may be employed, as by Hebra, so that the 
patient remains in the water for from four to eight hoars in the 
day; or be medicated by the addition of sulphur, tar, or other 
substances, so as to combine a medicative with a macerative 
effect. In private practice, these baths are much less available 
than in hospitals. When the eruption is generalized and an 
excessive macerative effect is derived, the rubber clothing an- 
swers a better purpose. I am in the habit m such cases of order- 
ing an undershirt and drawers made of soft rubber cloth, of the 
size of the undergarments usually worn by the patient, the latter 
wearing these for several hours of the day. The sweating is 
often profuse and debilitating, to such an extent that the psori- 
asic skin will rarely tolerate the treatment for an entire day, or 
for even that part of it in which active labor is performed. By this 
means alone, it will at times be found possible to secure complete 
disappearance of the patches. 

In other more obstinate cases, or in those where for any reason 
such treatment is indicated, as upon the scalp and face, the sapo 
viridis may be employed with advantage in the soap and water 
treatment. The spiritus saponis kalinus (two ounces (60.) of 
the soap to one (80.) of alcohol) may be briskly rubbed over the 
patches by the aid of a piece of flannel or sponge, and then im- 
mediately washed off with the oil and scales in a surplus of hot 
water, or be left for a time in contact with the part. Hebra 
and Kaposi make use of a species of soap paste, made by rubbing 
into each patch a small quantity of the green soap to which a 
little water is added till the proper consistency is obtained. 
These inunctions are repeated twice daily for six days. The 
epidermis becomes then brownish-colored, and in three or four 
clays afterward exfoliates in lamellae. Then a general bath 
cleanses the surface. In the French hospitals, a somewhat speed- 
ier method is pursued. On the evening of the first day, the 
patient is anointed with the green soap which he retains upon 
the skin during the night. In the morning he takes an alkaline 
bath, and immediately after is thoroughly anointed with lard. 
This is repeated on the second and third days, after which the 
patient is usually ready for any topical medication of the dis- 
eased parts. 
14 



210 



DISEASES OF THE SKIN 



F«>r the yet more obstinate cases in which the exfoliation of 
the epidermis is not readily induced, still more energetic meas- 
ures have been adopted, such as the local use of fan-tic acids 
and alkalies, scrubbing the patches with nail-brushes, floor- 
brushes, etc., and tlic use of clean, white sand. 

Once ready for topical medication, the patches may first be 
subjected to the local action of tar, a remedy which has long 
enjoyed the highest reputation for the relief of the disease. It 
should be remembered, however, that its value depends largely 
upon its application to patches where it will he tolerated. In 
very young patients, and in those whose skins are irritable, or 
who are suffering from what may well be termed acute phases 
*>\' \ soriasis. it may prove highly injurious by aggravating the 
disorder. The rule should be, to employ it at first tentatively 
over a relatively small portion of the surface, upon which the 
medicament should remain for several hours, as tar will not in 
all cases promptly produce its injurious effects. These are, sub- 
jectively, a sense of heat and pain, and, objectively, the other 
signs of inflammation, heat, redness, and swelling. Occasion- 
ally its eifeet upon the sebaceous -lands is manifested in what 
llehra has termed " tar-acne." 

Pix liquida, the oil of white birch, or, less preferably, the oil 
of cade, may lie used, generally in the proportion of a drachm 
(4.) to the ounce (oO.) of vaseline or lard. A thin stratum of 
such an ointment may be painted over or well rubbed into the 
patch several times in the day or merely at night. In Vienna, a 
still more energetic effect is secured by using the soft soap freely 
over the patches while the patient is in the bath, then anointing 
him with tar, and finally returning him to the bath where he 
remains for from four to six hours. For localized eruptions, the 
green soap in combination with tar and alcohol serves an ex- 
ceedingly useful purpose, either in the proportion of equal parts 
of the three ingredients, or by combining them in various pro- 
portions, as. for example: — 
li. Baponis viridis, 

01. picis, f 

Glycerin., $ 

01. rosraarini, 

Spts. Yin. red if., 'Oss ; 500 

M. et Big. For external use. 

Other combinations oi' service are Bulkley's liquor picis alka- 
linus, the formula of which has been already given, 1 and Wil- 
kinson's ointment as modified by llehra, the latter combining 
the remedial effects of sulphur, lard, soap, and grease. The for- 
mula is as follows: — 

K. Sulphur. Buulimat. 
01. cadini, 
Baponis \ iridis, i 
Adipis, $ 

Cretae praeparal . 
Sig. " Wilkinson's oil 



.~.i> s 



130 

30 



I 


a § §ss ; 


10 




aaij; 


30 


tnent." 


B'jss; 


3 


1 See p. 


134. 





PSORIASIS. 211 

This is a remedy of remarkable value when employed exter- 
nally, not only in psoriasis, but in a long list of other cutaneous 
diseases. The chief objections to its use in private practice are 
its stench and its liability to produce chemical action upon met- 
als with which its vapor comes in contact. 

Absorption of any tarry compound applied externally may 
result in general toxic symptoms, including fever, vomiting, 
diarrhoea, strangury, and elimination of the toxic agent in secre- 
tions which are blackened by its presence. These symptoms 
are usually relieved in from twenty-four to forty-eight hours 
after the discontinuance of the drug. 

Next to the tars, as regards the treatment of psoriasis, ranks 
deservedly chrysarobin or chrysophanic acid, a crystalline pow- 
der of the color of old gold, insoluble in water, but readily dis- 
solved in hot alcohol, acetic acid, benzol, vaseline, and hot fat. 
It is derived from the "goa-powder" of the East Indies, or the 
" araroba powder" of Brazil, whose employment in psoriasis was 
first recommended by Mr. B. Squire, of London, Eng., in 1878. 

In 1880 I collected specimens of this powder from the leading 
chemists of Boston, ISTew York, Philadelphia, and Chicago, and 
finding these to vary greatly, both as regards the color of the 
preparation and the therapeutical effects induced, I have since 
exclusively employed the Brazilian araroba em po l with better 
results. 

The drug is best applied in the form of an ointment, varying 
in strength from half a scruple (.666) to a scruple (1.333) to the 
ounce (32.) of vaseline or cerate. It is used by others in greater 
strength, but with the pure specimen to which I have called 
attention, it is liable in larger proportions to produce disa- 
greeable effects. These are declared in a hot, itching, swollen, 
irritable, and erythematous skin, stretching from the surface of 
application, with tolerable uniformity, in every direction. It is, 
even in the strength named above, necessary to begin its use 
with caution, testing it by application first to a limited area of 
integument. These excessive effects usually subside in a few 
days. An ignorant woman to whom a chrysarobin ointment 
was given by me in 1879, with directions to test it carefully at 
first by application over the elbows of her daughter, stripped 
the latter before an open fire and rubbed the ointment over the 
entire surface for the space of half an hour. The result was an 
intense erythema lasting for six days with considerable distress, 
and the complete disappearance of the psoriasis, which did not 
fail to reappear in eight months. 

When the drug produces its most brilliant effects, the pso- 
riasic patch, previously denuded of its scales, assumes a whitish 
and normal aspect, contrasting thus somewhat remarkably with 
the chocolate to brownish-black discoloration of the normal skin 

1 This article has been imported for me from Messrs. Silva, Limaos and Co., 
of Bahia, Brazil. 



212 DISEASES OF THE SKIX. 

at the periphery. This coloration, when produced either by the 
ointment directly or by a frequenl transfer of its ingredients to 
other parts by the medium of the clothing and hands, involves 
also the nails, hairs, and under-linen of the psoriasic patient. 
Its employment upon the face and scalp is thus largely inter- 
dicted. The staining of the skin and its appendages disappears 
entirely in time, but always slowly. 

An improved plan of using chrysarobin externally, lias been 
recently suggested by Fox, of New York. 1 

A soft paste is made by rubbing the chrysarobin with a suffi- 
cient quantity of water and smeared upon the psoriasic patches, 
the scales of which have been previously removed by one or 
more hot baths, with soap friction. As soon as the paste has 
dried, which it does in one or two minutes, a layer of collodion 
should he allowed to How over each patch and to harden into a 
protecting coating. This will remain in place for several days, 
or longer, according to the location of the patches; and when it 
tails or is washed off, the application of the powder and the col- 
lodion should he repeated. By this procedure the chrysarobin 
in full strength is kept in contact with the affected skin, and 
prevented from exciting undue inflammation of surrounding 
parts or staining the clothing. A mixture of the powder and 
the collodion may be used, hut it is less efficacious. A film of 
collodion doubtless interferes with the action of the aeid upon 
the skin. A somewhat similar plan consists in the use of gutta- 
percha tissue to retain a strong chrysarobin ointment in contact 
with psoriasic patches. The edges of this tissue will adhere 
tightly to the skin if a small camel's-hair brush, dipped in chlo- 
roform, lie passed rapidly beneath them. 

Contrary to the views of man}' dermatologists, I esteem pyro- 
gallic acid, first suggested as a remedy for psoriasis by Jarisch, 2 
as inferior to chrysarobin. The fact that several deaths have 
now been reported as consequent upon its use, should deter 
many from making trial of it, in a painless and merely dis- 
figuring disease. It is used in a ten percent, vaseline ointment; 
is effective, though less rapid in its effect than chrysarobin; is 
cheaper; is odorless and painless; and discolors to a less extent 
the sound skin. Both remedies are capable of being absorbed 
from the surface and of producing constitutional symptoms, py- 
rexia, strangury, and blackish evacuations. But in the case ^t 
pyrogallic acid only, so far as is known to me, have these symp- 
toms resulted fatally. 

Kaposi' 1 has hee'n lately employing beta, naphthol in psoriasis, 
(as also in eczema), the formula of which is, (J )0 1I 8 0. It may he 
applied in alcoholic solution. Under tlie employment of a fifteen 
per cent, ointment, the author reports speedy disappearance of 

i Medical News, March 18, 1882, p. 289. 
* 8chmidt's Jahrb., 1880, No. ::. 

3 Wien. Med. Woehenscli., May 28, June 4, and 11, 1881. 



PSORIASIS. 213 

psonasic patches. It did not stain the skin, hair, or nails, and 
thus certainly bids fair to supersede the tars in the treatment of 
the disease, especially in patches upon the scalp and face. 

Balmanno Squire, 1 however, reports that the naphthol was, 
in certain experiments, conducted by himself, without appre- 
ciable effect when used in the strength of from ten to twelve 
per cent.; and that when he increased the quantity of the agent 
till the ointment was applied in the strength of twenty-five and 
even fifty per cent., there was the production of merely irritative 
effects. 

Crocker, of London, similarly uses thymol in ointment, half 
a scruple to half a drachm (0.666-2.) to the ounce (82.); and 
"Williamson advises turpentine, two drachms (8.) to the ounce 
(.30.) of olive oil with the odor corrected by the oil of lemons. 
Charteris treated thus a single limb of a psoriasic patient, which 
was subsequently wrapped in wool, with the curious result of 
relieving the psoriasis of the other limb, possibly in consequence 
of the absorption of the remedy. The danger of strangury in 
such cases must not be overlooked. 

The nitrate, as well as the iodides and oxides of mercury, are 
applied by many practitioners in the form of ointments to 
patches of psoriasis, usually few in number, and limited in ex- 
tent. The action of these agents is, however, inferior to those 
already named ; and, the range of their availability being quite 
limited, they should be esteemed lightly in the local treatment 
of the disease. 

Prognosis. — Inasmuch as no treatment will insure the perma- 
nent relief of psoriasis, such a result should never be either pre- 
dicted or promised. The disease is one which frequently recurs, 
and may do so for a lifetime. It, however, disappears completely 
at times, without subsequent recurrence, and when this alto- 
gether exceptional and fortunate issue is secured, both patient 
and physician can well congratulate each other on the result. 
In many cases, I am fully persuaded, heterodoxical though the 
belief may be, that the psoriasis calls for no treatment. " Such 
are the extremely indolent cases, where the patches exist in 
middle-aged adults upon the parts of the body entirely protected 
by the clothing. It is then harmless, painless, and in no sense 
annoying, save as it occasions unnecessary mental disquietude. 
It is far less burdensome than the spectacles which others have 
to support upon the nose; or the plate which may have to re- 
main in permanent contact with the palate ; or the suspender 
which is constantly demanded by a largely pendulous varicocele. 
It is, in short, in such cases, much more of a deformity than a 
disease, and, as compared with the uncertainties and discomforts 
of prolonged treatment, may often be better tolerated with a 
patient equanimity. 

1 Brit, Med. Jour., Jan. 14, 1883. 



214 DISEASES OF THE SKIN". 



Pityriasis Maculata et Circinata. 

Under this title Duhring in this country, as also Bazin and 
other French authors, have described a rare disease of exudative 
type, non-contagious, and benign in character, occurring sud- 
denly or gradually both in children and adults. It is character- 
ized by the conspicuous appearance over large surfaces of the 
trunk, especially the integument covering the clavicles, ribs, and 
scapulas, of numerous pin-head to small coin-sized, circumscribed, 
roundish or ovalish, Blightly elevated, macular or maculo-papu- 
lar lesions. These may be discrete, closely set together, or con- 
tinent, and instead of being elevated may he either on a level 
with the general surface, or even slightly depressed, with an an- 
nular border. They are dry, covered with furfuraceous scales, 
and vary in color from a yellow or tawny shade to a deep red. 
The infiltration is slight, the patch being superficially situated; 
and the subjective sensations insignificant, rarely more than a 
moderate pruritus. At times, Duhring has noted a central heal- 
ing and peripheral extension of the disease. 

The lesions accomplish a stadium of from one to three months, 
new crops meantime appearing, after which involution occurs, 
and is completed within a few weeks by desquamation, with the 
production of some pigmentation. 

The disease is distinguished, by the absence of a fungus, from 
all the affections of the skin induced by vegetable parasites. It 
should not be confounded with seborrhcea of the trunk, lichen 
ruber, psoriasis, and syphilis. 



Pemphigus Vulgaris. 

Deriv. Gr. wsu*^, a bladder. 
Pemphigus vulgaris is a disease characterized by febrile and other symptoms 
of constitutional disturbance, accompanied by the production of a series of 
pea- to egg-sized cutaneous bullae, irregularly distributed over the surface, 
and distended with serum or blood. 

S'lniptomalology. — The cutaneous lesions in this disease are 
usually preceded by febrile symptoms; and the disturbance of 
the economy is declared in cardiac, respiratory, and gastrointes- 
tinal derangements of function. The fever may he continuous, 
remittent, or intermittent ; and is usually exaggerated just before 
the appearance of a fresh crop of blebs. 

The eruption first appears in reddish maculae of rather vivid 
line, in the centre of each of which appears later a whitish ele- 
vation of the epidermis suggesting a wheal. Either upon these 
or unaffected points of the skin, tense, well-rounded bullaa sub- 
sequently form, varying in size from a pea to a lien's egg and 
even larger, and in number from three or six only, to a hundred 
and more. They are usually irregularly distributed (pemphigus 



PEMPHIGUS VULGARIS. 215 

disseminatus), but may be clustered in groups; or very rarely be 
found, tbe younger encircling the older lesions, so as to form a 
circinate appearance (pemphigus circinatus); their contents are 
serous, bloody (pemphigus hemorrhagica), or later purulent, 
with color corresponding to these fluids. Whether ruptured or 
not, the involution of the lesion is accomplished by desiccation 
and crusting, the crusts being usually found to contain blood, 
pus, epithelial debris, and the exudate from the base of the bleb. 
Beneath such a crust a new epidermis forms, which is usually 
violet, purplish, or bluish-red in color; and, later, displays a 
brownish pigmentation which may for several weeks survive the 
disease. 

Occasionally the affection occurs with very mild and even in- 
significant phenomena (pemphigus benignus). There may be no 
fever, and a very few blebs appear; in some cases but a single 
lesion can be seen (pemphigus solitarius). In other instances 
the fever is intense; the eruption abundant; the skin cedema- 
tous, painful, pruritic, excoriated; and the underlying lymphatic 
glands enlarged. This general condition with exacerbations and 
remissions may persist for months, and the eruption then disap- 
pear never to return; or to recur, as it often does, in the future. 
Fortunately the disease is rare. 

The lines technically drawn between man}^ diseases are quite 
artificial, however useful and necessary for systematic study and 
classification. Clinically, many of these distinctions disappear. 
This is especially true of the varieties of pemphigus. Between 
the benign processes just considered and the grave form of pem- 
phigus foliaceus, described in another chapter, several interme- 
diate gradations can be observed ; and even the most benign may 
at times unexpectedl} 7 assume the most malignant phases. Pem- 
phigus malignus is a name given generally to those intermediate 
varieties of the disease, most of which are distinguished by per- 
sistent and prostrating fevers; cachexia, especially in infants; 
the occurrence of diphtheritic patches upon or about the lesions 
with infiltration of the derma and slouch of its superficial layers; 
or extensive crusting and even subsequent ulceration. A form 
is described by He bra and Kaposi, in which vegetations and fun- 
gosities rise from the base of the blebs. Pemphigus pruriginosus 
is another grave form of the disease, in which the lesions give 
rise to an intense pruritus, under the scratching induced by 
which they are torn, excoriated, and commingled with the 
crusts and exudations of an artificially engendered eczema. Sev- 
eral of these malignant and intermediate forms may terminate 
fatally. 

In all varieties of the disease, the lesions may be exhibited upon 
the mucous membrane of the accessible outlets of the body. 

Etiology and Pathology. — The cause and nature of pemphigus 
vulgaris are so obscure that they may be said to be unknown. 
The disease is more frequently encountered in infancy and child- 



216 DISEASES OF THE SKIN. 

hood, because, if would seem natural to conclude, the powers of 
resistance al a tender age are inferior to f Lose of a mat urn- epoch. 
The disease is in general observed in debilitated patients, who 
are variously described as suffering from "nervous prostration," 
"mental worrv ami exhaustion," "neurasthenia," "general de- 
bility," visceral disorders, and impairment of nutrition. Occur- 
ring in a vigorous, rosy-checked, strong-limbed adult, the disease 
would certainly he regarded as a curiosity. It is therefore safe 
to conclude that those states in which there is marked impair- 
ment of bodily vigor, are particularly favorable to the develop- 
ment of the disease. In such, there is less tendency to the 
formation of a plastic exudate; and the protoplasm of the body, 
instead of reproducing itself in actively multiplying lumps dis- 
played regularly along its reticulum, produces a liquid in a con- 
dition of very languid activity. 

Diagnosis. — From what has preceded it will be inferred that 
pemphigus vulgaris is a name given to a disease, and not merely 
to bullous lesions upon the surface of the skin. It is of some 
importance to remember this fact, as several authors have used 
the term in a purely descriptive sense, the fact, being that bullae 
are manifestations of several disorders, including syphilis, lepra, 
pemphigus foliaceus, herpes iris, and erythema multiforme. 

At the outset, consequently, the blebs of pemphigus vulgaris 
can scarcely be differentiated from those of other diseases. It is 
necessary for its recognition that proper consideration be had of 
all the cutaneous and other phenomena present in the disease. 
In syphilis, such lesions are rare in the adult, and relatively more 
frequent in infants hereditarily diseased. With the latter, the 
blebs are usually seen at birth, often upon the palms and soles, 
and are frequently superimposed upon an exulcerated base. The 
coexistence of mucous patches of the mouth, vulva, and anus 
with the evident polymorphism of the lesions and signs of grave 
cachexia, will usually indicate the nature of the disease. The 
cutaneous symptoms of such infants are improperly designated 
as pemphigus. Such an eruption is a bullous syphiloderm. 

In the bullae of lepra, there is usually coexisting cutaneous 
anaesthesia, and the involution of the bleb is followed by a strik- 
ingly characteristic atrophic patch, usually pigmented and insen- 
sitive. In pemphigus foliaceus, the extraordinary and usually 
generalized desquamation which ensues, is sufficiently distinc- 
tive, though it must he home in mind, as heretofore stated, that 
the several varieties of pemphigus may he transformed, the one 
into the other, by well-nigh insensible gradations. Among its 
graver forms susceptible of such transformation may be named, 
impetigo herpetiformis, pemphigus cachecticus, pemphigus diph- 
theriticus, and pemphigus pruriginosus. 

In herpes iris, the Lesions are more vesicular; much more tran- 
sitory; subject to a concentric arrangement and variation with 
respect to color; and are situated more frequently upon the ex- 



PEMPHIGUS VULGARIS. 217 

treraities, especially the backs of the hands. The bullous lesions 
occasionally seen in urticaria and erythema multiforme are to be 
recognized by the other characteristic symptoms of those dis- 
eases; in the former, more particularly, by their intermingling' 
with typical wheals; and in the latter, by the location of the 
eruption, and its climatic or seasonal significance. The so-called 
contagious forms of pemphigus, epidemics of which have been 
described by Besnier, Hervieux, and other French authors, were 
presumably, as Dnhring well suggests, instances of impetigo con- 
tagiosa. This inference is sustained by the frequent allusion of 
the writers named to the " varicella form" appearance of the 
lesions. 

Lastly, the external application of eantharides, mezereon, the 
stronger acids, alkalies, and other chemicals may be followed by 
blebs produced either by accident or intention with a view to 
feigning; disease. The intentional production of such symptoms 
is usually effected upon the anterior faces of the lower extremi- 
ties, regions within easy reach of the right hand. Erysipelas 
and. dermatitis calorica are also diseases in which blebs appear, 
always, however, of minor significance as compared with the 
other symptoms of disease present. The same may be said of 
the bullse which form upon a gangrenous integument. 

Treatment. — The internal treatment of pemphigus vulgaris is 
a matter of importance, as will be suggested by even a brief 
consideration of the constitutional states in which it occurs. 
Mr. Jonathan Hutchinson, of London, Eng., in his valuable 
Lectures on Clinical Surgery, 1 distinctly asserts his belief that 
" arsenic is a specific for the state of health upon which relapsing 
pemphigus depends." In many years' trial of this remedy, he 
declares that, in his own practice, he has never recorded a single 
failure, though he makes exception, properly, of many infantile 
cases supposed to be syphilitic. The remedy is certainly a valu- 
able one, but should be employed with the same caution and in 
accordance with the rules already prescribed in the chapter on 
psoriasis. Kaposi, however, declares that he has been unable to 
obtain favorable results from its employment. Iron, quinine, 
strychnia, and the mineral acids are certainly indicated in many 
cases, in conjunction with a particularly nutritious diet. Cod- 
liver oil and the malt preparations now in the market should 
not be neglected. 

]STot infrequently the treatment should be directed to the relief 
of the anomalous performance of the sexual function in women, 
as the disease has been found to occur in the hysterical and 
chlorotic states sufficiently common as a result of such dis- 
order. 

The local treatment of the lesions should consist, first, in a 
puncturing of each bleb with a fine needle, in order to give exit 

' London, J. & A. Churchill, 1878, p. 49. 



218 DISEASES OF THE SKIN. 

to its contents, which should be carefully removed from the skin 
by the aid of cotton-wool. Then the parrs are to be thoroughly 
enveloped in an inert dusting powder. When there is consider- 
able pyrexia with heal and distress in the skin, the Burfaee may 
be treated as in acute eczema, with oleated lime-water, contain- 
ing als«. opium or dilute hydrocyanic acid in some such propor- 
tions as those already detailed. 

The ordinary lead and opium Wash, with or without the addi- 
tion of the oxide of zinc, will also answer a good purpose. 

In Vienna, the continuous water hath still enjoys the highest 
favor. Kaposi has kept one patient day and night for eight 
months with his body thus immersed, to the great advantage of 
the latter. Unfortunately such a course is well-nigh impracti- 
cable outside of a large hospital. 

Prognosis. — The prognosis in pemphigus vulgaris, though much 
less grave than in the malignant forms of the disease, should 
always be formulated with caution. Unlike several of the dis- 
eases heretofore considered, the affection is one not frequently 
encountered in persons of fair general health. The constitu- 
tional condition of the patient must be carefully considered ; 
nor should it be forgotten that the disease is not only one liable 
to relapses, but also one in which the graver may succeed the 
more benign manifestations. A flaccid summit of the bleb,san- 
guinolent or ichorous contents, an abundant efflorescence, and a 
rapid succession of new after t\\a involution of more ancient 
lesions, are in general unfavorable symptoms. The same be said 
of degeneration of the floor of the bleb, after rupture and dis- 
charge of its contents. 



The disorders next to be considered are mainly distinguished 
from those already named, by the gravity of their features, and 
the frequency with which they are conducted to a fatal issue. 
The distinction thus sought to be established, is of importance 
chiefly on clinical grounds. In the exceptional cases where a 
more favorable result is obtained, persistent lesion-relics rarely 
remain in the skin to mark there the traces of the ancient dis- 
ease-process. In this respect, the diseases now to be described, 
resemble those discussed in the chapters which have preceded. 

Dermatitis Exfoliativa Generalis. 

General exfoliative dermatitis is a disease characterized by erythematous, vesicu- 
lar, bullous, or pustular cutaneous lesions, involving the whole or the greater 
portion of the surface of the integument, succeeded by extensive desquama- 
tion, accompanied by febrile disturbance, and terminating often in marasmus 
and death. 

The condition which is now generally recognized under the 
title given above, occurs typically in two distinct forms, pity- 



DERMATITIS EXFOLIATIVA GENEKALIS. 219 

riasis rubra and pemphigus foliaceus. It can hardly be denied 
to-day, however, that, clinically, intermediate forms can be recog- 
nized between the two extremes, thus justifying their considera- 
tion under a common term. 

Pityriasis Rubra. 

The disease which is recognized by authors under this title, 
is characterized throughout its course by a superficial hyperemia 
and inflammation of the skin, declared by a diffuse redness of a 
vivid or lurid tint, and an abundance of small, large, or lamellated, 
bran-like scales, which are continuously exfoliated from the epi- 
dermis throughout the course of the disease. Patients rarely 
present themselves for observation till a considerable portion of 
the surface is involved; but Kaposi states that in two cases ob- 
served by him the disease was first noticed in the neighborhood 
of the articulations. There are never at any time other lesions 
of the skin, betrayed in vesiculation, pustulation, moisture, or 
crusting. The palmar and plantar surfaces are usually less dis- 
tinctly reddened than the face and extremities, having at times 
even a pallid hue; but they are always covered with a distinctly 
scaling epidermis. 

Under pressure with the finger, the redness subsides or assumes 
a yellowish shade, while, as a rule, when the integument is 
gathered up betw r een the finger and thumb, no thickening and 
infiltration can be recognized. Exceptions to this have been, 
however, noted by several observers, by myself among the num- 
ber, in an interesting case made the subject of a clinical lecture. 1 
The temperature of the skin is slightly increased. The exfolia- 
tion is, as the disease progresses, one of the most striking of its 
characteristics, the scales accumulating in large quantities about 
the coverings of the body of the unfortunate patient, who is en- 
gaged, as a French writer has it, in the labor of stripping him- 
self involuntarily of his epidermis. 

The disease persists for months and years, always more severe 
in expression as it advances, the papery scales being shed more 
abundantly and in larger flakes, leaving beneath them a smooth, 
shining, occasionally purplish or even cyanotic skin. In the 
cases observed by Jamieson, 2 of Edinburgh, and myself, the skin 
was soclark-hued as to suggest the color of the mulatto. Grad- 
ually the patient is conscious of an increasing sense of chilliness, 
as if deprived of sufficient bodily covering. The itching may be 
absent, moderate, or severe. Later, the integument seems to 
retract, as if insufficient to encompass the body, and becomes 
subject to fissure from extension and contact, while the lower 
extremities may even be oedematous. This retraction may be so 
marked that ectropion of the lid may ensue, and the wide open- 

1 Pityriasis Rubra: Cliic. Med. Jour, and Exam., Feb. 1881. 

2 Edinburgh Med. Jour., April, 1880, p 879. 



220 DISEASES OF THE SKIN. 

ing of the mouth become difficult. The Lairs and nails lose 
their lustre and become triable, often falling, though at times 
escaping altogether. 

The influence of this gigantic, epidermal catarrh, involving, as 
if decs finally, wwy portion of the body, does not fail, toward 
the end, to be perceived by the vital forces. Alternating chills 
and febrile processes, pneumonias of a low grade, colliquative 
diarrhoea, tuberculoses, subcutaneous abscesses, bed-sores, and 
even gangrene of the skin, may close the scene. 

I [ebra and Kaposi have together had under observation " about 
fifteen" patients affected with pityriasis rubra who, with a single 
exception, died from its effects. It will be seen thus that the 
disease is exceedingly rare. A few interesting- cases have been 
reported by English authors. Among Americans, I believe that 
Duhring, Geo. II. Fox, of jSTew York, and myself, have alone 
published reports of c;ises. The disease is one of early or middle 
life, and preeminently of the male sex. 

Etiology. — The causes of the disease are absolutely unknown. 
It will be seen that the small number of cases which have been 
recognized, has furnished but an insignificant field for the study 
of the malady. It is interesting, however, to note in this con- 
nection, that the constitutional symptoms of each case seem to 
have been induced by the disease of the skin, and not the latter 
by any internal derangement of which the symptoms are made 
manifest. For not only do these visceral troubles occur chiefly 
at a late period of the malady, when common observation suffices 
to show that the cutaneous mischief alone is sufficiently exten- 
sive to induce them, but it is also clear, from the wide range of 
these disorders (bowels, lungs, etc.), that no special visceral 
malady has excited the cutaneous disease. 

Pathology. — The researches of Hans Ilebra 1 have demonstrated 
in two cases, that there is in the earlier period of the disease an 
infiltration of the integument moderate in degree, succeeded at 
a later period by cutaneous atrophy, in which the rete and pa- 
pilla- of the corium disappear. The connective tissue elements 
undergo sclerosis; and the glands and the follicles of the skin 
are destroyed. Pigmentation is abundant. Both he and Fleiseh- 
niiiii have discovered coincident pulmonary, intestinal, or cere- 
bral tuberculoses; and Kaposi, in one post-mortem examination, 
established an atheromatous condition of the uterus. 

Diagnosis. — It is scarcely necessary to add to the facts given 
above, that many cases loosely reported as instances of pityriasis 
rubra, are not really such. The misinterpreted symptoms are 
often those of an unusually extensive psoriasis or chronic squam- 
ous eczema, which commonly terminates favorably in the course 
of a proper treatment. I have been summoned to see several 
such eruptions, whose import has been misunderstood. 

1 Vierteljahr. f. Derm. u. Syph., lift. 4, 1876, p. 508. 



DERMATITIS EXFOLIATIVA GENERALIS. 221 

Psoriasis rarely extends over the entire surface of the body, 
but it will be at times thus generalized. In these very excep- 
tional forms, a long history of typical psoriasic patches ma} 7 usu- 
ally be obtained, while the bleeding surface beneath the scales 
and the character of the latter, will point to the true nature of 
the disease. Psoriasis occurs in healthy, pityriasis rubra in 
cachectic constitutions. Extensive erythematous or squamous 
eczema, apart from all other symptoms, can be recognized at 
once by the excessive distress occasioned by the eruption. The 
patient lies in bed nursing his or her tender limbs, back, or 
belly. In pityriasis rubra, the patient rises, dresses himself, and 
moves about with an expression, not of pain, but of listless 
apathy. His scales are not scanty and adherent, but abundant 
and exfoliating freely. There is, from first to last in his case, 
no history of moisture' In very generalized eczema, there will 
be always, at one point or another, a surface which weeps. In 
its early periods, pityriasis rubra can be distinguished from pem- 
phigus foliaceus by the absence of bulla?. When, however, there 
is present merely a generalized exfoliative dermatitis, the two 
disorders are, in my belief, often indistinguishable. 

Treatment. — Arsenic administered internally seems powerless 
in pityriasis rubra. Cases are on record of fatal results after 
the exhibition of this drug in prodigious quantities for long 
periods of time. Tar externally promises no better. Kaposi 
reports a single case relieved by the use of carbolic acid inter- 
nally. 

A roborant treatment, including the employment of cod-liver 
oil, iron, and quinia, is certainly indicated, with the simplest 
bland unguents externally. Of the latter, vaseline seems best 
tolerated. It should be employed, not merely to soothe, but also 
to protect the skin. The clothing should be ample and unirri- 
tating; and the diet carefully selected with a view to supporting 
the strength. 

The prognosis is necessarily grave. 

Pemphigus Foliaceus. 

In this disorder bullse form, which, instead of developing so 
as to freely project from the surface, as in pemphigus vulgaris, 
are flaccid, imperfectly distended, and, in cases, having a roof- 
wall scarcely raised from the tissues beneath. The relatively 
scanty, clear, or cloudy fluid which they contain, seems to push 
the limits of the chamber in which it is imprisoned, in a cen- 
trifugal direction, so that its mode of operation may be loosely 
compared to that of urine extravasated just beneath the skin. 
Below this elevated epidermis, no new tissue forms, so that the 
derma becomes exposed in patches as large as a saucer and even 
larger. The floor, thus exposed, is seen to be reddened and 
oozing. The exudate dries into friable and thin crusts, which 



222 DISEASES OF THE SKIN'. 

become mingled with the effete epidermic plates forming the 
ancient roof-wall of flattened bullae; the whole producing finally 
a picture of generalized desquamation from the surface of the 
body. The extension over the entire surface is reached rather 
more slowly than in pityriasis rubra, but, once accomplished, the 
two diseases unquestionably merge by common phenomena. 
The hairs fall; the nails arc rendered friable; the integument 
becomes apparently insufficient for the covering, and certainly 
incapable of permitting the usual movements, of the body. Fis- 
sures open ; ectropion ensues ; a violaceous or deep pigmentation 
of the skin becomes perceptible. Emaciation, fever, diarrhoea, 
furunculosis, ulceration, gangrene, and death are the common 
chain of sequences. Grayish-hued, flattened blebs may also be 
seen in the mouth (velum, tonsils, epiglottis, and buccal mem- 
brane), the epithelium of which becomes detached in sodden 
masses, leaving behind a lurid-red, smooth, or ulcerated surface, 
which may interfere with articulation, deglutition, and even 
respiration. 

As has been stated in considering the subject of pemphigus 
vulgaris, the grave forms of the disease may originate in those 
which are commonly described as benign. The etiology, patho- 
logy, diagnosis, and treatment of the disease, have been practi- 
cally considered in the two preceding chapters. The prognosis 
is grave, as the disease, with i'ew exceptions, results fatally. 



General exfoliative dermatitis, when once fully developed, 
seems to present certain essential, definite, clinical features which 
have a character of their own. These are universal, progressive, 
epidermal exfoliation, and the consequent condition of maras- 
mus into which the patient falls. The accidents of this process 
seem to be fissures, infiltration, subjective sensations of pain, 
itching, etc., contracture of the integument, ulceration, subcu- 
taneous abscesses, gangrene, and visceral tuberculoses. If it be 
objected that pityriasis rubra and pemphigus foliaceus should 
be disassociated, because the former is a dry and non-discharging 
disease, and the latter a moist and exuding affection, character- 
ized always at first and often at last by the occurrence of blebs, 
the answer is sufficiently simple. The same arguments precisely 
which demonstrate the identity of erythematous, papular and ves- 
icular eczema, will indissoluble connect the two affections under 
consideration. The day in which diseases were classified by their 
elementary lesion has passed, [t is the occurrence of interme- 
diate forms which is the all-important fact. Jamieson 1 cites 
several Buch which are strikingly suggestive; and others are 
on record. The two diseases unquestionably merge, the dry ex- 
hibiting often a change to the moist or bullous form, and the 

1 Loc. cit. 



IMPETIGO HERPETIFORMIS. 223 

latter undergoing an inverse metamorphosis. When the causes 
are known which determine that one patient shall have a papu- 
lar, and another a pustular eczema, then it may be possible to 
explain why this general exfoliative dermatitis which destroys 
life is characterized by dryness; and that, by an ill-conditional 
fluid exudate forming an imperfect bleb. 

Impetigo Herpetiformis. 

Impetigo herpetiformis is a cutaneous disease of women, frequently compli- 
cating the puerperal state, characterized by the occurrence upon the skin and 
mucous membranes, of concentrically grouped pustules, and by a febrile con- 
dition which usually terminates fatally. 

Symptomatology. — Our knowledge of this rare disease is limited 
to the reports of eight cases observed in the Vienna clinic by 
Hebra and Kaposi; one in ISTew York, by Heitzmatm ; and a 
few scattered cases recorded by others. The patients were all 
women, and these usually in the puerperal state. Pin-head sized 
pustules, usually closely packed together in groups, tilled with 
an opaque or yellowish-green fluid, are discovered upon the sur- 
face of their groins, axillee, breasts, and several other portions of 
the body. A dirty-brownish-colored crust is formed by the rup- 
ture or desiccation of these lesions, and about this, single, double, 
or triple concentric circlets of new and similar lesions appear in 
succession, each series undergoing a similar process of involution. 
The eruption thus extends till the circlets from different foci of 
origin unite; and extensive areas of the skin are involved. Be- 
neath the crusts the skin is reddened, infiltrated, smooth, covered 
with a new epidermis, moist, as in eczema, or exhibits a denuded 
corium. It is never in a statu of ulceration. In the course of 
three or four months, the eruption is well-nigh universal, the 
skin being swollen, shining, and crust-covered, or seamed with 
excoriations here and there surrounded by circlets of pustules. 
The lingual mucous membrane exhibits grayish, centrally de- 
pressed patches, well-defined in contour. Alternate rigors and 
febrile accesses, mark the periods of recrudescence when new pus- 
tules form. Delivery seems to have had no favorable effect upon 
the course of the disease occurring in pregnant women. An 
endometritis with peritonitis was discovered, post mortem, in a 
single case. One woman only, of the eight Vienna patients, 
survived; and she suffered front a relapse after several weeks of 
improvement. 

The etiology and pathology of the disease are necessarily ob- 
scure, having in view the relatively small number of reported 
cases. Duhring describes a much milder malady of similar type, 
occurring in women not pregnant. Kaposi is inclined to asso- 
ciate the disease with a pathological condition of the uterus. 
Heitzmann thinks it related to pemphigus. Besnier and Doyon 
conclude the disease to have a septiceemic origin. In Vienna, 



224 DISEASES OF THE SKIN. 

the treatment has been conducted by the aid of carbolated or 
alkaline baths, dusting powders, anodyne and carbolated oint- 
ments, and a mixture of plaster and coal tar. 
The prognosis is necessarily grave. 

Lichen Ruber. 

JDeriv. >«ix" v . moss. 

Lichen ruber is an exudative cutaneous disease, characterized by the appearance 
of firm, minute papules, conical, flat, or oven uinbilicated at the apex, whose 
evolution may be accompanied by a moderate degree of itching, the eruption, 
when unmodified by treatment, having a marked tendency to generalization 

and the induction of marasmus. 

Symptomatology.— Under the form lichen ruber, Hebra was first 
to describe one of the two forms of disease which are now recog- 
nized as equally entitled to the appellation. These are lichen 
ruber acuminatus and lichen ruber planus. 

In 

Lichen Ruber Acuminatus, 

pin-head sized, conical, reddish, scale-capped papules of con- 
siderable firmness, are disseminated abundantly over the surface 
of the skin, often in circles or lines, occasionally occurring first 
about the articulations, and in the course of a few months 
covering the entire surface in a well-nigh confluent eruption. 
The skin becomes then thickened, infiltrated, reddened, fis- 
sured, and scaling, the papules being at times no longer discern- 
ible. In unmitigated cases, the condition at this period resembles 
the later stages of general exfoliative dermatitis. The hairs 
fall, the movements of the body are accomplished with pain, 
and the extremities are maintained in a position midway be- 
tween flexion and extension. The integument is generally red- 
dened, covered with innumerable delicate scales, and, especially 
upon the palmar and plantar surfaces, thickened by dense 
infiltration. Over the deeper fissures, extending to the corium, 
blackish and blood-containing crusts form. The nails are thick- 
ened, friable, opaque, aud project from their matrices. Emacia- 
tion progresses pari passu with the invasion of the disease; 
and death results from exhaustion. In this country, the dis- 
ease is of exceeding rarity. 

Lichen Ruber Planus, 

occasionally seen in America, is the only form of the disease 
which I have had the opportunity of observing in this country. 
In it. the papules are glazed, waxy, umbilicated, scaling at the 
apex only alter they have existed for some time, pin-head to 
rape-seed in size, and roundish, angular, or oval in contour. 
They are usually firm and particularly well characterized by the 



LICHEN RUBER. 225 

minute punetiform depression of the flattened apex, described as 
an " urabilication." They are at tirst irregularly disposed, but 
later tend to arrange themselves in groups about the flexor as- 
pects of the wrist and knee, the palmar and plantar surfaces, 
the lips, lids, cheeks, shoulders, penis, and other parts, as of the 
trunk and limbs. Often, as the lesions persist, they become flat- 
ter, assume a dark-brownish shade, and surround themselves 
with closely-packed, newer lesions in circlets or parallel lines. 
In this way distinct, sepia-tinted patches may form, whose pro- 
gressive involution leaves dark-brown atropine depressions in 
the skin, suggesting cicatrices. The itching may be moderate 
or severe. The eruption is chronic in its course ; tends to linger 
for years within distinctly circumscribed areas; and seems to 
exert upon the constitutional forces a much feebler influence 
than the acuminate form of the disease. As it is much more 
amenahle to treatment, it has been less studied in its unmiti- 
gated features, but Kaposi thinks that in the majority of cases 
it would, if unstayed, become generalized. In one ca.se only, 
has he noted the occurrence of emaciation and other symptoms 
of disturbance of the general economy. 

Etiology. — The causes of the disease are unknown. The sexes 
seem to suffer in equal proportion. The disease is neither trans- 
mitted by heredity nor contagion. In those who display the 
symptoms of the affection, external irritation is capable of aggra- 
vating the eruption. The disease is chiefly encountered in mid- 
dle life, but has been observed as early as the eighth month. 

Pathology. — The anatomical changes in the skin have been 
studied by Neumann, Biesiadecki, Obtulowic, and Kaposi. 
These seem to agree in pointing to the outer root-sheath of the 
hair and the perifollicular tissue, as the early seat of the disease. 
Here the hair follicle exhibits a bud-like prolongation, in conse- 
quence of hyperplasia of its elements, which involves finally the 
peri-follicular papillae and the rete above them. The umbiliea- 
tion is the result of central atrophy of the papillary layer. 
Pathologically, the two forms of the disease are discovered to 
depend upon a similar disease-process, a fact further borne out 
by the clinical evidence afforded by individuals displaying inter- 
mediate forms between the two extremes and even, at one and 
the same time, typical lesions of each variety. 

Diagnosis. — Lichen ruber is readity distinguished from moist 
forms of eczema by the absence of discharge and moisture, fea- 
tures present only in the most advanced stages of the first-named 
disease. 

Papular eczema exhibits lesions whose career, and whose ab- 
sence of umbilication and of angularity of outline, are sufficiently 
characteristic. From patches of psoriasis, the grouped papules of 
lichen ruber are distinguishable by the discovery in the latter of 
individual lesions of characteristic form. Pityriasis rubra and 
pemphigus foliaceus in their final stages might indeed be scarcely 
15 



220 DISEASES OF THE SKIN. 

excluded from lichen ruber acuminatus in a similar period. It 
yel remains to be determined whether the first may not represent 
the erythematous, the second, the bullous, and the third, the 
papular phase of a generalized exfoliative dermatitis, in which 
occurs a profound nutritive impairment of the tegumentary 
organ with a subsequent disturbance of the other organs of the 
body. 

Treatment — Arsenic is of greater value and can be employed 
with larger chances of success in lichen ruber, than in any other 
cutaneous disease. The drug is to he early given, persistently 
pushed in the face of new crops of lesions, till the desired result 
is obtained, and continued for several months after all signs of 
the disease have disappeared. Tonics when indicated, should 
always he exhibited. Kobner, 1 and others, have had remarkable 
success when using the metal by hypodermic injection, even 
after its failure by the mouth. 

The local treatment is naturally employed chiefly for the relief 
of any pruritic sensation. Here the dusting powders and oint- 
ments prove serviceable. The local remedies employed in cor- 
responding stages of eczema may, in brief, be here used with 
advantage. In Vienna, however, the tarry compounds have not 
been found as useful as in chronic eczema and psoriasis. Naph- 
thol promises better. 

Prognosis. — The prognosis of the disease, when it refuses to 
yield to treatment and tends to become generalized, is necessarily 
grave. Treatment after the occurrence of marasmus, will gene- 
rally be found ineffectual. The acuminate justifies a graver 
prognosis than the plane form of the disease. Untreated lichen 
ruber acuminatus will usually terminate fatally. Properly 
treated lichen ruber planus, fortunately the form well-nigh exclu- 
sively found in this country, may prove an obstinate but benign 
malady. 

Prurigo. 

Deriv. Lat. prurire, to itch. 

Prurigo is a chronic, exudative, cutaneous affection, common^ beginning in 
infancy or early childhood and continuing through lii'e, characterized by the 
occurrence of minute, pale or reddish papules with extensive infiltration and 
intolerable pruritus. 

Symptomatology. — In this affection, pin-head to rape-seed sized, 
firm, whitish or reddish-white papules form, chiefly and prima- 
rily upon the extensor faces of the extremities, hut from these 
localities extending gradually over the entire surface of the body. 
The itching they occasion is of the severest type. 

The earliest symptoms are usually displayed in the latter por- 

1 Berl. Klin. Woch., Dec. 3, 1880. 



PRURIGO. 227 

tion of the first year of life, in the form of an urticarial rash, 
which persists and is finally succeeded by typical papules. The 
latter are minute, often sub-epidermic, and become rapidly 
covered with blood-stained crusts in consequence of the induced 
scratching. Then ensues a long train of symptoms, including 
pustulation, fissures, excoriations, dense infiltrations, crusts 
formed of exuded serum and dried blood, oedema, diffuse dark- 
brown pigmentation of the surface in large areas, and consequent 
adenopathy. Fully developed, the disease presents in general 
the same physiognomy in different patients of different ages. 
The lower extremities always exhibit the severest manifestations 
of the disease, especially the thigh and leg as distinguished from 
the foot; though the trunk, forehead, cheeks, neck, arms, and 
head may be also involved. The protected surfaces, as of the 
axillae and groins, except as regards adenopathy, are free from 
the disease. The general health of the patient manifestly suffers 
from the insomnia and nervous agitation induced by the state 
of the integument. Emaciation, malnutrition, and cachexia 
are common sequelae. The mental and moral tone of the patient 
thus harassed from early childhood throughout an entire life, is 
necessarily profoundly impaired. 

Mild and severe forms of the disease are recognized in Aus- 
tria (prurigo mitis and prurigo ferox or- agria). Incessant 
care, judicious treatment, climatic influences, and the comforts 
of life commanded by wealth, seem to determine the difference 
between the two. 

Etiology. — The disease occurs chiefly in Austria, few eases 
being recorded elsewhere. A patient was, however, recently 
exhibited at the International Medical Congress in London, 
whom both Kaposi and II. Hebra recognized as affected with 
prurigo. "Wigglesworth and Campbell have reported cases in 
this country. It is needful to remember that the term prurigo 
is here employed to designate the disease recognized by some 
authors as the "true prurigo of Hebra." It should never be 
confounded with pruritus, which, under various usages, may be 
the title of a mere symptom of a disease. Prurigo is more often 
encountered in the male sex ; is never contagious, and never 
induced by lice; but, according to Hebra and Kaposi, may be 
grafted upon an hereditary predisposition. "Scrofula," tuber- 
culosis, malnutrition, " misery," poverty, anaemia, and filth, are 
held to be severallj r favorable to its development. Unquestion- 
ably the superior resources of the poorest classes in America 
will long protect them from the incursion of this inveterate 
malady. The only approach to the disease which I have seen 
in this country, occurred in the person of a male immigrant 
from Germany, whose skin was deeply pigmented and thickly 
set with minute papules on a densely infiltrated integument. 
He had suffered tor twenty years, but could not give a clear 
history of his condition in childhood. 



228 DISEASES OF THE SKIN. 

Pathology. — Kaposi practically admits that, Btriking as is the 
clinical portrait of this disease, its anatomical features are indis- 
tinguishable from severe forms of obstinate papular eczema. 
The microscope reveals merely an hypertrophy of the various 

elements of the epidermis and derma, deposits of pigment in the 
corium, thickening of the root-sheaths of the hairs, enlargement 

of the cutaneous muscular elements (erectores pilorum), and a 
consequent atrophy of the integument which has long been the 
seat of the disease. 

Diagnosis. — Remembering the extreme rarity of prurigo in 
America, it is to be distinguished chiefly from the various forms 
of papular eczema by the location of its lesions and the course 
of the disease. From pruritus, it is readily diagnosticated by 
its general physiognomy and history; its peculiar pigmentations 
and infiltrations; and by the special region chiefly affected. 
But, both diseases may complicate prurigo, especially eczema, 
which is then ordinarily of artificial origin. In pediculosis 
vestimenti, the parasites will usually be found upon the under- 
clothing, while the lesions induced by the nails never form 
closely packed papules. There is something highly characteris- 
tic in the widely separated excoriations, puncta from wounds of 
the insects, and inflamed papules seen upon louse-bitten patients. 

Treatment. — In Vienna, sulphur, tar, green-soap, baths, and 
frequent anointings with oily and fatty substances have occa- 
sionally served to ameliorate the severe symptoms of the disease. 
Mercury, carbolic acid, salicylic acid, boracic acid, the diachylon 
and zinc ointments may also be employed upon different portions 
of the skin, when indicated. Internally, arsenic has proved 
valueless, while carbolic acid has occasionally seemed beneficial. 
Cod-liver oil and the ferruginous tonics with the bitters, will 
naturally be indicated in many patients suffering from mal- 
nutrition. 

Prognosis. — The disease usually persists through life. The 
most favorable conditions are those where the patient is quite 
young and surrounded by circumstances which permit of un- 
tiring provision for all his needs. 

Zoonoses. 

A number of diseases of the lower animals are transmissible 
to man, many of them with fatal result. Of these, some are 
attended with cutaneous symptoms, or display the latter as their 
chief morbid manifestations. 

Equinia (Glanders, Farcy, Maliasmus) 

is, as the term implies, derived exclusively from the horse. It 
is a contagious disease; manifested after a brief incubative period, 
either by grave constitutional symptoms which are not preceded 
but followed by an affection of the skin; or beginning with a 



ZOONOSES. 229 

circumscribed phlegmon which rapidly passes through the stages 
of suppuration, gangrene, involvement of the lymphatic vessels 
and ganglia, and metastatic abscesses. Death usually results 
from septicemia, though recovery msiy occur after elimination 
of the poison, with great resulting prostration. The constitu- 
tional symptoms are, severe chills, high fever, and articular 
pains. When the cutaneous eruption succeeds the fever, there 
may be a generalized pustular eruption somewhat resembling 
the variolous exanthem, or numerous abscesses filled with an 
hemorrhagic pus. The mucous lining of the air-passages secretes 
an abundant, ichorous, puriform fluid. (Edema, erysipelas, ulcer- 
ation and gangrene are common complications. The disease is 
in a high degree contagious; and is said to be communicable to 
grooms and others who merely sleep in the stables where infected, 
animals are stalled. 

. Pustula Maligna. 

Tins is a disease of the same character as the preceding, orig- 
inating in those who have been brought into contact with the 
living or dead bodies, especially the hides, of animals infected 
with the "charbon." It is first manifested, usually upon the 
dorsum or other parts of the hands or face, to which the virus 
has had access, by the occurrence of an inflammatory and pru- 
ritic papule which is rapidly transformed into a blood-filled bleb, 
reposing upon a somewhat painful, engorged and often densely 
indurated base. One or more similar lesions may follow in the 
surrounding integument, coalescence of which produces a large, 
angry, cedematous and often gangrenous ulcer. The involved 
skin may be as large as a small coin, or of the size of the palm 
of the hand. The lymphatic vessels and ganglia enlarge and 
often suppurate; metastatic abscesses form; and the constitu- 
tional symptoms supervening are those described in connection 
with equinia. Death results from shock, septicaemia, or exhaus- 
tion ; though in cases where the lesion is circumscribed and 
unattended by constitutional symptoms, recovery may ensue. 

The attention and interest of the scientific world have been 
lately attracted to the experiments conducted by Pasteur and 
Toussaint with a view to securing immunity against these and 
similar disorders of the lower animals. By a so-called " vacci- 
nation" with " attenuated" fluids in which bacteria (supposed 
to be efficient in the transmission of these diseases) have been 
carefully cultivated, those gentlemen have unquestionably suc- 
ceeded in conferring a degree of immunity upon some of the 
animals experimented upon. It is probably too early to speak 
with confidence upon the brilliant results which many have thus 
been led to anticipate. 

In establishing a diagnosis of these and similar disorders, care 



230 DISEASES OF THE SKIN. 

must be taken to avoid one source of error. These affections 
are, in this country, extremely rare, but occasionally various 
cutaneous eruptions are induced upon the hands, after contact 
with animals or hides upon which chemical solutions have been 
applied for the destruction of lice. These solutions usually con- 
tain arsenic, corrosive sublimate, and other substances capable 
Of exciting a localized dermatitis. 

The treat incur of these maladies is to be conducted on the 
principles of genera] therapeutics. Popper, 1 an Hungarian phy- 
sician with a large experience in malignant pustule, reports suc- 
cess by deep excision of the lesion, extending the operation to 
the subcutaneous connective tissue. This lias always proved suc- 
cessful when practised before the occurrence of general symptoms. 

Hebra was not in favor of the early cauterization of the ma- 
lignant pustule, and it may be considered as a questionable 
method of procedure. 

A grave case of malignant pustule is recorded, 2 in which re- 
covery ensued after the hypodermic injection of the tincture of 
iodine. Three syringefuls of the pure tincture were deposited 
beneath the skin at the periphery of the diseased surface, and 
lint soaked in the same was applied over the slough. Internally, 
fourteen drops of the tincture (1.) with three grains (.26) of the 
iodide of potassium, were also administered. Normal cicatriza- 
tion followed in this and six other cases recorded. 



3. Hypertrophic. 

Molluscum Epitheliale. 

Deriv. Lat. mollusctis, soft. 

Epithelial molhisca are smooth, globoid, or acnmiiiiite bodies, situated either 
within or upon the skin, and in the latter case either sessile or pedunculated, 
varying in color from a yellowish-white to a dark-red, and in size from that 
of a pin-head to that of a bean. 

Symptomatology. — Molluscum epitheliale, a disease first recog- 
nized by Batcman, in 1817, under the title molluscum conta- 
giosum, is to be distinguished from another, known for a long 
time as molluscum fibrosum. The two disorders are perfectly 
distinct, and no longer to be confounded by a similarity in their 
names. 

Typical mollusca are firm, roundish bodies, averaging in size 
the dimensions of a pea, and in color varying from a waxy 
whitish hue, nearly that of the integument, to the dark-red tint 
of all injected masses. They are either imbedded in the skin, 
or project from it in semi-globular tubercles, sessile, or pedun- 

' Cthltt. f. Chir., 1881. No. 33. 

2 Archives Gen. de Med., Feb. 1882. 



MOLLUSCUM EPITHELIALE. 231 

ciliated. Usually a dark-colored aperture can be detected at the 
apex or side of the lesion from which, on pressure, milky and 
curd-like, semi-fluid contents can be made to exude. Occasionally 
inspissated, or even horn-like masses project from these orifices, 
as though forced out by a vis-a-tergo. The disease is rare, and 
the lesion usually single and isolated, though hundreds may ap- 
pear upon the person of one individual. They consist of semi- 
fluid collections derived from that portion of the rete which 
either lines the sebaceous glands or penetrates between the pa- 
pillae of the derma, or transformations of the latter into corni- 
fied amorphous deposits, surrounded by thickened parietes. 
They may be artificially removed; or be shed spontaneously; 
or inflame, suppurate, and result in circumscribed abscesses; or 
terminate by ulceration. Most often they are insidious, and slow 
of development ; and may persist for years without producing 
annoyance or subjective sensation. They occur on the face, the 
sides of the neck, and the nucha: on the penis and scrotum of 
the male, and the breast and labia of the female ; on the trunk ; 
on the flexor surfaces of the extremities, and the dorsal surfaces 
of the hands and feet. They are most common in children. In 
consequence of the depression of the centre of the little tumors 
(which Hutchinson has aptly likened to small pearl buttons), 
they may suggest the lesions of variola, and are hence described 
by French writers under the term, varioliform acne. 

Etiology. — In England, where the disease was first recognized, 
and where, according to Hutchinson, it is far more frequent than 
on the continent of Europe, the belief in its contagiousness is 
quite generally accepted. Excellent authorities are, however, 
divided upon this question. At present, therefore, it can only 
be definitely stated that the contagiousness of moll use urn is not 
yet established. If contagious, the lesions certainly possess this 
power of transmission in a feeble and imperfect degree, one much 
inferior certainly to other lesions recognized as contagious. 
Retzius and Wigglesworth succeeded in producing the disease 
by the medium of the molluscous contents. I have expressed 
the contents of dozens of these lesions, and have never yet seen 
evidence of their contagious qualities. Experiments with inoc- 
ulation have been generally unsuccessful. The proofs of conta- 
gion rest chiefly upon the circumstance of lesions observed simul- 
taneously or successively on the breast of a mother and the mouth 
of her suckling child; or upon the successive development of 
mollusca in several members of one family. These are generally 
explicable as coincidences. Fox, of New York, has called atten- 
tion to an interesting relation which would seem to subsist be- 
tween mollusca and verruca, or ordinary warts. If ordinary 
warts are ever shown to be in a feeble degree contagious, it can 
scarcely be doubted that a demonstration of the contagiousness 
of mollusca will soon follow. 

In the absence of proofs of contagion, it can merely be said 



232 



DISEASES OF T II K SKIN. 




that the etiology of the disease is unknown It is as difficult 
to explain the origin of a molluscoii8 tumor on the face of a little 
girl, as to account for a wart <>n the hand of a boy. According 
to Kaposi, eczema, sweating, pruritus, and maceration of the 
skin, predispose to their occurrence. 

Pathology. — Upon section, a typical molluscous tumor is found 
to contain either a thick caseous fluid, or a mass of smooth, 
whitish and roundish bodies, which are often clustered aboul a 
short stalk. Microscopically, these are seen to he composed of 
epidermal masses, fat globules, and peculiar bodies of oval shape, 
partly or wholly contained in an epi- 
thelial pod, the so-called " molluscous 
corpuscles." 

The origin and significance of these 
corpuscles have been the subject of a 
great deal of careful investigation, and 
no little divergence of opinion as to 
the result. The disease by many 
authors has been consequently re- 
garded as one concerning the seba- 
„ ., ceous glands; and the fluid or more 

Molluscons corpuscles. 1 i • 1 ■ 

(After Kaposi.) or ' esS solid contents ot the tumors, 

as the result of the various metamor- 
phoses which the pent-up secretion of those glands underwent. 
By such authors the disease is termed " molluscum sebaceum," 
" contagiosum," etc.; and is classified with the sebaceous gland 
disorders. 

But the later studies of Retzius, 1 Lukomsky, 2 Renaut, 3 Vidal, 4 
and Thin, 5 make it clear that, the disease is one which concerns 
chiefly the rete mucosum of the epidermis. Believing this- to 
be the real source of these tumors, I have, by agreement with 
Dr. Duhring, who also makes use of the same term in the third 
edition of his treatise, employed in the designation of the dis- 
ease the name molluscum epitheliale, first suggested in this con- 
nection by Yirchow, in the title epithelioma molluscum. 

Molluscous tumors may evidently take origin either in the 
portion of the mucous layer whose involution forms the lining 
membrane of the sebaceous gland, or in the prolongations of the 
rete downward between the papilla? of the corium where there 
is no follicle. In either situation, the molluscous elements are 
earliest recognized as simply enlarged epithelia which assume, 
as a consequence of this enlargement, a globular form. In the 
midst of these, there are certain individual elements which ac- 
quire a granular appearance, the granular masses finally giving 



' Viertel. f. Dorm, und Byph. iv. lift. 3, 1877. 2 Virchnw's Archiv, Bd. lxv. 
s Lyon. MmL, July 25, 1880. ' 8oc. <!<■ Biologie, 1877-1S78. 

5 Jour. of Anal, ami Phys., vol. xvi., 1881 ; and Brit. Med. Jour., Jan. 15, 1881. 



MOLLUSCUM EPITHELIALE. 233 

place by union to a globoid or oval shaped body, large, shining, 
and stratified or homogeneous. This is the molluscous corpuscle 
which represents a colloid metamorphosis of the original epi- 
thelia. According to Ranvier, the stratum granulosum of the 
epidermis is composed of" elements which contain minute par- 
ticles of a substance called eleidine, the keratogenic material by 
whose transformation the stratum corneum is actually produced. 
This substance Renaut declares to be abundantly deposited in 
the enlarging corneous glohes characteristic of molluscum; and 
the process is by him declared to be identical with that occurring 
in the transformation of the elements of the mucous into those 
of the horny layers of the skin. The pathological resemblance 
of certain molluscous bodies to epithelioma is thus very clearly 
suggested. 

According to Thin 1 the internal root-sheath of the lanugo 
follicle is the original source of the disease, whence molluscous 
elements pass to inoculate, at various points about the follicular 
orifice, the adjacent epidermis. The coalescence of these points 
forms the tumor, in the course of the development of which the 
lanugo hair is shed, and the sebaceous gland disappears. 

Diagnosis. — Mollusca resemble the lesions of variola more 
than any other cutaneous phenomena. They are, however, 
readily distinguished from the latter by their chronicity, their 
semi-fluid contents, the absence of febrile symptoms, and the 
career of the variolous pustules. From warts the}^ are also dif- 
ferentiated by their contents, hemispherical shape, and the dark 
punctum, almost invariably present on one part or another of 
the lesion. 

Molluscum epitheliale in no way suggests molluscum fibrosum, 
with which it has only been confounded in consequence of the 
similarity in the two names. The tumors of molluscum fibrosum 
are solid new growths, usually occurring in great numbers upon 
the trunk of individuals in adult years. They may attain enor- 
mous dimensions of several pounds weight, and though in cases 
they degenerate by ulceration, they never have the curdy con- 
tents of molluscum sebaceum. 

Papillary warts are to be distinguished from mollusca, though 
without question lesions are to be occasionally seen of a type 
intermediate between the two forms. Warts are to be recog- 
nized by their general papilliform character, and their evident 
relation to the papillary layer of the corium overlaid by a thick- 
ened stratum corneum. 

I have, on several occasions, been consulted by patients who 
have discovered mollusca upon the genitals, and who supposed 
these lesions to be of venereal origin. An error in this respect 
can scarcely be committed by the physician. Neither the solid 
papule of the initial lesion of syphilis when observed on the 

1 Loc cit. 



234 



DISEASES OF THE SKIX. 



skin of the penis, nor the pustule and resulting ulcer of the 
chancroid, arc ever characterized l>y the particularly waxy-look 
of genital mollusca with their depressed puncta. In such c 



Fig. 24. 







The author's case of nit.iiu.scum epitbellale. (From a painting in oil.) 

the inguinal glands should always be carefully examined, remem- 
bering, however, that a forcibly squeezed and cauterized mol lus- 
t-urn may be accompanied by a sympathetic adenopathy. 



KERATOSES. 235 

Treatment — Molluscous tumors may be removed by ligature, 
scissors, knife, or curette, their contents having been previously 
expressed. When desired, the surface may be first chilled or 
frozen with the ether spray, to diminish the pain of the trifling 
operation. Bleeding is easily arrested by a pledget of lint. 
Occasionally the point of a crayon of nitrate of silver m&y be 
introduced after their removal, either to check hemorrhage or 
to insure destruction of the cyst. According to Hebra, the 
return or' the complaint, when it occurs at all, may be expected 
in points where no tumors have been removed. 

When the lesions are small and numerous, they may be made 
to exfoliate by the local application of green soap. Removal of 
the larger lesions may be followed by minute cicatrices. 

Prognosis. — The disease can always be terminated by removal 
of the tumors; the process to be repeated in cases of recurrence. 
Cicatrices, when these result, are of trifling moment. 

Keratoses. 

JDeriv. G-r. xipus, a horn. 

The disorders recognized as keratoses are due to an hypertro- 
phy which may involve preeminently either the epidermis or 
the corium. They are hence readily separable into two classes: — 

A. KERATOSES DUE TO EPIDERMAL HYPERTROPHY. 

Callositas (Tyloma). 

Callosities are superficial, circumscribed, dirty-white or yel- 
lowish-white, flattened, thickened, and horny patches of epi- 
dermis, dense in structure and usually insensitive. A section 
of the plaque shows it to he largest at the centre and least at the 
periphery. They vary in size from a finger-nail to a section of 
a hen's egg, being at times larger; and occur chiefly upon parts 
of the integument subjected to intermittent pressure, as the 
hands and feet ; also upon parts stretched over osseous promi- 
nences, as those over the ischia. They may be complicated by 
hyperemia, fissure, acute inflammation, or erysipelas; and read- 
ily serve as foci of cutaneous disease (eczema, psoriasis, etc.). 
They are commonly encountered among mechanics, carpenters, 
shoemakers, etc. ; among persons wearing ill-fitting shoes, stock- 
ings, or surgical apparatus; among workers in metals, acids, or 
heated substances; and among musicians (harpers, banjo-players, 
etc.). They are produced exclusively by external causes, pres- 
sure, friction, chemical agents, and heat. By careful considera- 
tion, they can be readily distinguished from eczematous, psori- 
asic, and ichthyotic patches, being always limited to the sites 
of external contact. 

Callosities require treatment only when they are sources of 
pain or discomfort. They may be removed; surgically, by the 



23G DISEASES OF THE SKIN". 

knife: chemically, by the destructive action of acids or alkalies; 
rationally, by disuse of the part to an extent sufficient to inter- 
fere with the operation of the cause. When painful, they may 
be poulticed. A nightly soaking of the part with warm oil, 
kept in contact with the thickened epidermis during the hours 
of sleep, by a compress of flannel saturated with the same sub- 
Btance, will in the end always soften the induration. 

Clavus. (Corn.) 

Corns are similar hypertrophies of the epidermal layer of the 
skin, with the peculiarity of presenting inferiorly a coniform 
prolongation, which, being pressed from without inward upon 
the sensitive papilla? of the corium, excites pain in various de- 
grees. They vary in size from peas to large chestnuts, and are 
dense and callous when occurring upon those prominent parts 
of the foot where the hoot, shoe, or gaiter, exercises its greatest 
pressure. When occurring upon the lateral face of a toe in ap- 
position with another, the corn originates usually from pressure 
through the medium of the neighboring digits. It is then softer, 
from exposure to greater heat and moisture. Corns are often 
weather-sensitive, being unusually painful before, during, or after 
the occurrence of storms, ami should therefore not be confounded 
with gouty or rheumatic deposits below the skin. They are 
composed of superimposed, and often concentrically arranged, 
layers of epithelium, between which are occasionally found 
minute hemorrhagic extravasations. They are occasionally seen 
upon the palms of the hands. 

Corns are rationally treated by disuse of the feet, or the ad- 
justment of properly-fitted coverings for the same. They 
usually fall spontaneously after an attack of paraplegia, and in 
the case of the lower extremities confined for a few weeks in 
surgical apparatus for relief of a fracture. They may be softened 
by prolonged maceration in water, poultices, or, best of all, oil, as 
in the treatment of callosities. Erasion and excision may be prac- 
tised, if demanded by an exigency. Where the sufferer must 
necessarily continue to use the foot, the simplest and best treat- 
ment is as follows: The part is thoroughly macerated for half 
an hour, with water as hot as can be tolerated. Then the pro- 
jecting callous portion of the corn is gently removed by cutting 
or scraping, till, as nearly as may be. the surface is level with 
the plane of the adjacent skin. The part is then dried, and the 
entire surface, both of the seat of the corn and the adjacent in- 
tegument, is completely covered with many narrow, short, and 
nicely adjusted strips of Maw's moleskin plaster. When the 
trifling operation and dressing are complete, the patient should 
bear firm pressure over the corn without flinching, and walk 
witli perfect comfort. The plaster remains till it separates spon- 
taneously, which is usually in the course of a few days. The 



KERATOSES. 



237 



corn is then macerated at night with an oil poultice, as described 
above, and the dressing afterward reapplied, usually the second 
time by the patient. Persistence in this course is followed by 
complete relief if the coverings of the feet be properly fitted. 
Caustics, employed by many, are usually unnecessary when there 
is no ulceration of the hard corn ; and are in this situation fre- 
quent sources of great distress. They are chiefly valuable in 
the treatment of the soft variety ; but should always be applied 
with a skilled hand. 

Cornu Cutaneum. (Cutaneous Horns.) 
Cylindrical, conical, straight or twisted, angular, and other- 
wise irregularly shaped and sized corneous eminences, single or 

Fie. 26. 




Varieties of cutaneous horns. 



multiple, are occasionally seen projecting from the scalp, fore- 
head, nose, lips, ears, penis, and extremities. They are named 



238 DISEASES OF THE SKIN. 

from their resemblance to the similar appendages in horned cat- 
tle, but widely differ from the latter, which are always im- 
planted upon osseous tissue. They are formed of dense mid 
massed columns of epithelin, often resting upon somewhat pro- 
longed papillae. Occasionally, on section, they exhibit the con- 
centric arrangement of the epithelia seen in corns, hut, unlike 
the latter, have reentrant basal depressions into which the pa- 
pillae below penetrate. At times they are implanted in a dilated 
follicle, in which case the glandular elements participate in their 
formation. At times also, they represent a corneous transforma- 
tion of the epithelia which constitute warts. They are seen in 
all colors, hut are often brownish-black, with a fissured or 
wrinkled exterior, like rough hark. They may lie painless, or, 
like the other keratoses, become the seat of inflammation in 
various grades. They may be short, or several inches in length. 
The largest specimen ever under my observation, was seen by 
nie in France, on the forehead of a male, where it had existed 
for fifteen years. It measured three inches in length. A few 
cases have been recorded in this city. They may be shed spon- 
taneously, never to return, or shortly to reappear. They occa- 
sionally develop into epitheliomata, as has occurred once under 
my observation, in a gentleman over sixty years of age, whose 
epithelioma developed from a horn on the dorsum of the right 
hand, projecting about three-fourths of an inch. 

Horns may be removed by extirpation, after which the surface 
upon which thej' were implanted should be carefully and com- 
pletely cauterized. 

B. KERATOSES DUE TO HYPERTROPHY OF THE DERMA. 

Verruca. 
Deriv. Lat. verruca, an excrescence. 

Warts arc cutaneous excrescences; sessile or pedunculated; 
pointed or flat; smooth, rugous, or having a cauliflower appear- 
ance; pigmented in various shades or of the natural color of the 
skin; congenital or developing after birth. They maybe single 
or multiple, and occur upon the hands, feet, face, scalp, neck, 
genital, and other parts of the body. They may develop slowly 
or rapidly, and persist for years, or disappear without apparent 
cause. They may be soft, dense, or even corneous to the touch. 

The several names given to the various manifestations of 
warts, have chiefly a descriptive value. 

Vkkruca acuminata (condylomata) are filiform, papilliform, 
or coxcomb like vegetations. They are single or multiple; at 
times hundreds coexist upon the genitalia and neighboring 
regions. In size they vary from a pin-point to a hen's egg, and 
may be larger. They are apt to be moist and secreting; being 



KERATOSES. 239 

frequently covered with a puriform mucus of exceedingly nause- 
ating odor. Upon the genitals, they are encountered upon the 
glans, around the frsenum, and over the prepuce of the male; 
and in the female, about the clitoris, labia, vagina, and anus. 
They are usually of a bright red color in these situations. When 
occurring upon the integument, they are firmer, drier, and ex- 
hibit a feebler tendency to luxuriant vegetation. In this form 
they may be recognized about the axillary regions, the umbili- 
cus, the intercligital spaces of the feet, and even the face. Dr. 
Heitzmann once informed me that he had seen them covering 
the side of the chin. 

Verruca congenlta and Verruca acquisita are terms used 
to designate the lesions discovered at birth or later. 

Verruca filiformis. — This variety of wart differs somewhat 
from the others, not only pathologically, as is noted below, but 
in its clinical features. They are slender, thread-like, often 
pedunculated masses, usually covered with a smooth and appa- 
rently unaltered epidermis, occurring upon the neck, eyelids, 
chest, and ears of women. .Kaposi concludes that they represent 
minute fibromata. 

Verruca glabra is distinguished by its smooth surface. 

Verruca plana is the flattened or globoid, smooth or rugous 
formation like a plaque or button, usually pigmented, and occur- 
ring upon the back. 

Verruca senilis. — These are bean- to coin-sized growths 
developed upon the face, trunk, and extremities of persons of 
advanced years. They are fiat, usually pigmented, and have a 
granular aspect. They are readily separable by the finger nail, 
and are then found to rest upon a reddish granular base. As 
the result of external injury (caustics, traumatism) they may 
hecome the starting point of an epithelioma. 

Verruca vulgaris is the form most frequently seen upon the 
fingers and hands, pin-head to pea-sized, usually discolored, 
papilliform excrescences. 

Etiology. — The causes of warts are unknown; but in early 
childhood, a period in which they are most frequently encoun- 
tered, it is reasonable to conclude that they result from external 
contacts. It is when the child begins to handle everything 
within reach, that they usually first appear, and then about the 
hands. The acuminate or condylomatous warts are chiefly 
induced in parts moistened with a blennorrhagic secretion, but 
unquestionably may originate from contact with the leucorrhoeal 



240 



DISEASES OF THE SKIX. 



orpathological, oon-venereal discharges from the female genitals. 
I nave, however, never observed them in virgins of either Bex. 
The senile warts are more probably due to obscure changes in 
the nutrition of the integument. 

Pathology. — Warts on section exhibit, microscopically, an hy- 

Fi«r. 27. 




IP*** 



Vertical Bection of the summit of a pointed wart, a, papilla containing vascular loop : 
o, stratum corneum ; d, uypertrophied rete. (After Kaposi.) 



pertrophy of the papillary layer of the corium concerned in their 

iular loops 
mi. Above 



pertrophy ot the papillary layer of the corium concerne 
growth, with corresponding development of the vasci 
rising iron; the superior vascular plexus of the coriun: 



KERATOSES. 241 

these papillae the rete is usually largely developed, the epithelia 
beiug multiplied not only on the sides of the prolonged papillae, 
but immediately over their apices. In all the dry varieties the 
stratum corneum is also hypertrophied, but this more especially 
over the summit of the excrescence. The filiform warts are 
composed chiefly of a slender fasciculus of connective tissue 
springing from the bundles below, and covered with an epider- 
mis which is not apparently altered. Beneath all forms of warts 
there may be a substratum of sclerosed connective tissue, con- 
stituting the firm base upon which they rest. 

Treatment. — Warts may be removed by excision, erasion, or 
caustics (nitrate of silver, alkalies, acids, perchloride of iron, cor- 
rosive sublimate, etc.). The larger growths upon the genitalia 
are often highly vascular, and may demand the prior application 
of a ligature when they are pedunculated. Even the slender 
filiform warts will be found to contain a small vessel in the 
pedicle which requires cauterization after the excision. "When 
the warts cannot be more readily removed by the knife or curved 
scissors, I prefer the Paquelin cautery to all other measures. The 
blackened eschar which is left prevents hemorrhage, serves as 
the best subsequent dressing, and, in my experience, is less apt 
to be followed, by a return of the growth. In some cases, it is a 
useful expedient to transfix the lesion in several directions with 
the long needles used in gynseco logical practice, previously 
dipped in a fifty per cent, solution of chromic acid. 1 

Prognosis. — Warts are benignant growths; and in childhood 
and early adult life need not suggest grave sequelae. It is far 
different in advanced years, for, though these excrescences possess 
even then no malignant character, they are the too frequent pre- 
cursors of epithelioma. While it may be urged justly that the 
early lesions in such cases were really epitheliomatous and not 
verrucous ; the fact remains that many warty formations of appa- 
rently benign character do in advanced years, especially under 
the teasing of frequent cauterization, undergo a cancerous trans- 
formation. 

Multiple Cutaneous Tumor Accompanied by Intense Pruritus. 

Under this title Dr. W. A. Harclaway, 2 of St. Louis, describes 
a rare disorder characterized by the occurrence of about sixty pea- 
to nut-sized dense tubercles and tumors covered by a thickened, 
scaly, and excoriated, often hemorrhagic skin. In some situa- 
tions coalescence had occurred, forming thus, long and narrow 
plaques of nearly the width and half the length of the finger of 
an adult. The lesions were seen upon the outer aspects of the 

! The following is the formula according to which are prepared several of the 
preparations sold in the shops for topical employment in both warts and corns : 
Salicylic acid, gss (2.) ; extract of cannabis indica, grs. v (0.33) ; collodion, 
§ss(16.). 

2 Arch, of Derm., April, 1880, p. 129. 

16 



242 DISEASES OF THE SKIN. 

arms and legs, the palms and soles, the Bides of the fingers, and 
around the ankles, wrists, and elbows. The accompanying pru- 
ritus was intense and intolerable; and, having lasted for twenty- 
two years, was naturally associated with the degree of pigmenta- 
tion often observed under similar conditions. The patient was 
an unmarried woman, fifty-one years of age, and declared that 
the lesions first appeared as k> blisters." 

Specimens of these tumors, examined by Dr. Ileitzmann micro- 
scopically, exhibited hyperplasia of the epithelial and connective 
tissues. The papilla" were longitudinally elongated, branching, 
and provided with narrow capillaries. Numerous nests, greatly 
varying in size, and containing inflammatory elements with con- 
siderably enlarged bloodvessels, lay close beneath the papillary 
layer of the eorium. These elements showed all stages of transi- 
tion into basic substanee. The deeper layers of the derma were 
built up of very coarse bundles of connective tissue and numer- 
ous elastic fibres. 

Papilloma. — This term has been loosely applied to a large 
number of cutaneous growths widely differing from each other, 
both histologically and clinically. It has been made to include 
the vegetations of syphilis, the neoplasms of naevus, and even the 
tubercles of lupus. 

The designation, papilloma, is properly limited here to such 
cireumscrihed hypertrophies of portions of the skin as correspond 
with warts in their pathological significance. They may be de- 
fined as excrescences from the cutaneous surface, of a size con- 
siderably larger than all the varieties of the wart with the 
exception of the condyloma, usually presenting a luxuriant 
vegetation composed of elongated papillae, bloodvessels, and en- 
larged rete, covered externally with a smooth epidermis like a 
pellicle, or, more commonly, branched and tutted with the cauli- 
flower aspect, and then usually covered with a puriform mucus. 
The tumor inereases rapidly till it attains a maximum size, and 
then indolently persists. It is benign in character, and bears 
no relation to struma, carcinoma, syphilis, or lupus. It may 
occur upon any portion of the body. The cases observed by mo 
all occurred in women who were either pregnant or at the period 
of the menopause. 

Ichthyosis. 

Deriv. Gr. I^flt",-, a fish. 

Ichthyosis is .1 persistent disease of the skin, developed first in early infancy, 
and manifested in a general scaliness, in the formation of regularly outlined 
polygonal epidermal plates, or in the outgrowth of larger masses of a corne- 
ous consistency. 

Symptomatology. — The disorder briefly defined above, is one 
which displays a wide variation in its symptoms. To the ex- 
tremes in either direction two names are given, ichthyosis sira- 



KERATOSES. 248 

plex and ichthyosis hystrix. These, - however, represent merely 
accentuated types of a disorder rare in its fullest development, 
and, in its slightest, much more common, I am persuaded, than 
is generally believed. 

Ichthyosis simplex. — In the simplest manifestations of the dis- 
ease the skin of the patient can merely be described as unusually 
harsh to the touch, moistureless, and covered with adherent or 
exfoliating, fine scales. The latter are not massed, imbricated, 
nor displayed in plaques, and are usually of a dull yellowish- 
white color. It is rare that the practitioner is consulted for 
the relief of this disorder; it is usually discovered when the skin 
is exposed for other purposes (exploration, vaccination, etc.). In 
a still more advanced degree, the scales are massed together, 
forming grayish and whitish, polyhedral elevations or plaques, 
regularly outlined and closely set together, especially upon the 
extremities and certain portions of the trunk. Elsewhere the 
scaliness described above may be present in a more marked de- 
gree. Variations occur, in consequence of which the plaques, 
bordered distinctly by the natural lines and furrows of the skin, 
are even depressed, centrally or completely, or assume darker 
shades of color than those described, brownish and greenish- 
brown. 

Ichthyosis hystrix. — With and without the symptoms de- 
tailed above, the hypertrophy of the skin may, in circumscribed 
patches or larger areas, produce irregularly-shaped, verrucous, 
corneous, corrugated, wrinkled, or rugous masses, usually much 
darker in color than the patches seen in the simple variety of 
the disease, and more often also discovered in adult years. The 
resemblance is here rather to the rough bark of a tree than to 
the scales of a fish. In other still rarer cases, the excrescences 
assume a spinous, acuminate, or horn-shaped form. The hand 
passed over the surface perceives not only the excessive rough- 
ness, but also the dryness of the skin. Perspiration is imper- 
ceptible in the parts affected. The, nails are friable and indu-. 
rated; the scalp, scaly and covered with hairs of exceeding 
harshness. The palms and soles are ofteti spared. Kaposi de- 
scribed certain diffuse callosities occurring in the palmar and 
plantar regions differing from the ichthyotic patches elsewhere. 
The face is usually spared, but, when involved, only the slighter 
manifestations of the disease appear there, minute, superficial, 
scaly patches of a grayish tint. 



Ichthyosis is accompanied by insignificant subjective sensa- 
tions. The skin, indeed, of these patients seems inapt for the 
eczematous and other complications of the less diffuse keratoses. 
I have treated four ichthyotic patients for syphilis, and noticed 
in all a decided tendency to the production of lesions of the 



244 DISEASES OF THE SKIX. 

mucous surface without cutaneous complications. The extensor 
are usually more implicated than the flexor surfaces of the ex- 
tremities. 

Etiology. — Ichthyosis is unquestionably a congenital disease, 
though its first manifestations arc only apparent during the 
second year of life. It is said to be generally hereditary, but 
this should be accepted with some reserve for every individual 
case. One of ray ichthyotie patients was married to his own 
cousin, and had by her five children entirely free from cutaneous 
disease. None of his parents or grandparents were similarly 
affected. The disease occurs equally in both sexes, and is liable 
to aggravation in cold climates and the season of winter. The 
general vigor and development of patients thus deformed are, as 
a rule, quite unimpaired. Kaposi says : " The cause appears to be 
a local anomaly of the nutrition of the skin, especially involving 
its epidermic and fatty elements;" but this scarcely meets the 
requirements of etiology. 

Thost 1 describes ichthyosis occurring in four generations. Ac- 
cording to the ascertained genealogy, the ancestor first known 
to have suffered from this affection had five male children who 
inherited it, while one girl and one boy were spared. One of 
these diseased children had himself five children, of whom three 
males showed the disease, while one boy and one girl remained 
free. Another brother, of the second generation, had five male 
and three female children ; of these, four boj's and two girls be- 
came affected. One of the latter (of the third generation) bore 
four children, of whom three girls inherited the disease, while 
the fourth, a boy, escaped. It appeared that the affection always 
showed itself within a few weeks after birth, in the form of a 
roughness of the palmar and plantar surfaces. With the growth 
of the patient the condition constantly increased in severity, the 
epidermis shedding in large shreds until the disease reached its 
maximum by the fourteenth year. There was a marked dispo- 
sition to excessive sweating, particularly in the diseased locali- 
ties; the sensibility of the skin remained normal. Microscopic 
examination showed, in addition to the hypertrophied papillae, 
great development of the sweat, glands, with marked thickening 
of the ducts. Treatment failed to give more than partial relief. 

Pathology. — The diseased, or, better, deformed, skin is found 
microscopically to be hypertrophied in various degrees, accord- 
ing to the development of the malady; the proliferation of its 
elements occurring in connective tissue, papillae, stratum cor- 
neum, and bloodvessels. In well-marked cases of ichthyosis 
hystrix, the elongated papillae are surmounted by dense cones of 
the homy layer of the epidermis, more or less concentrically 
disposed, with sclerosis of the connective tissue, and a relatively 
unchanged rete. In this last particular, the dense plaque of 
ichthyosis differs in texture from the wart. 

1 Inaug. Diss. Heidelberg, 1880; Cbl. f Chir., No. 10, 1881. 



KERATOSES. 



245 



Diagnosis. — Ichthyosis not only presents features which are 
so characteristic as to be unmistakable, but also those which 
can be well-nigh perfectly portrayed in plates. In this respect 
it differs from a long list of cutaneous maladies. 1 

Were such necessary, aid of an important character can be 
gained in the history of the disease and in the entire absence of 
the lesions, lesion-relics and lesion-sequelse, common to all the 
exudative and scaling affections heretofore considered. 

Fig. 28. 




Ichthyosis hystrix, vertical section ; a, masses developed from the stratum corneum ; b, cones - 
formed by the rete ; c, hypertrophied papillae with dilated vessels ; d, dense connective tissue 
of corium, exhibiting numerous vessels transversely divided. (After Kaposi.) 

Treatment. — The younger the patient applying for relief, the 
larger are the chances of improvement and possible recovery. 
Ichthyosis hystrix of mature years is practically incurable. In- 
ternal treatment is valueless. External treatment is directed to 
softening, macerating, or anointing the skin, and, as far as prac- 
ticable, preserving it in a softer state. This is accomplished by 
frequent baths, alkaline, vapor, or combined with the use of 
soap or green soap, and generally followed by an anointing with 



1 The admirable representation of the ichthyotic skin in plate F, of Duhring's 
Atlas, is faithful in its exactness. 



246 DISEASES OF THE SKIN'. 

vaseline, dilate glycerine, or lard. The French, after the re- 
moval of the denser layers of the horny plates by the ai<l of soft 
soap and water, anoint the body by friction with the glycerate 
of starcli. Almond, cod-liver, neats-foot, and linseed oils, may 
be used after the bath. Only by the most assiduous perseverance 
is a desirable result obtained and permanently secured. In the 
Beverer hystrix varieties, the most annoying projections and ru- 
gosities may be removed by excision, the Paquelin knife, or, 
less preferably, by the aid of caustics. 

Prognosis. — Having in view the facts set forth above, it will 
be clear that in no case can a favorable result be anticipated 
with respect to a "■ cure" of the disease. Treatment, persistent, 
prolonged, and properly directed, may do much to improve the 
condition of the skin. 



Elephantiasis. 

Deriv. Gr. i\i$a<; elephant. 
Elephantiasis is a disease of the cutaneous and subcutaneous tissues, usually 
limited to certain regions of the body, preceded by the occurrence of some 
inflammatory process in the aff&cted part, and resulting in an enormous in- 
crease in its volume, with hypertrophy of the structures of ivhich it is com- 
posed. 

Symptomatology. — This disease, long known as elephantiasis 
Arabum, is encountered more frequently in and near the tropics, 
but sporadic cases occur in all countries. Perfectly typical in- 
stances of the malady have been noted in almost every part of 
the United States. 

Its most frequent seat is the lower extremity of one side, 
where it involves the foot and leg, though the thigh of the same 
limb may also enlarge. The penis and scrotum of the male, the 
labia and clitoris of the female, the upper extremities, the face 
and portions of the trunk may likewise become involved. 

The disease is insidious in its approach, and remarkably 
chronic in its career. Usually, localized inflammations precede, 
as an erysipelas or a dermatitis, with or without some involve- 
ment of the lymphatic glands. At the same time there is a 
condition of general fever. To this succeeds a defervescence, 
with abatement of the local inflammation ; its sequela? becoming 
manifested in a more or less persistent oedema of the part lately 
inflamed. After intervals of days, weeks, or months, the py- 
rexia recurs with still greater involvement of the swollen tis- 
sues, which, with each access of fever, increase in volume and 
gain in density. When the elephantiasic condition is fully 
developed, the skin is found to be tense, glossy and blanched, 
or discolored in various shades. Pressure upon the cedematous 
part is followed by pitting, but the tissue beneath is felt to be 
brawny and indurated. The parts beneath the skin are percep- 



ELEPHANTIASIS. 247 

tibly increased in volume, especially the subcutaneous tissue; 
and the circumference of a limb thus diseased may be several 
times larger than that of its fellow. A lymphangitis is usually 
declared by painful, cordlike, linear indurations of the part, 
associated with an adenopathy of the nearest ganglia. In older 
cases, the skin loses its glabrous aspect, and exhibits eczematous, 
verruccous, papillomatous, seborrheic, and even ichthyotic 
changes. Pigmentation, even to a blackish tint, may ensue; 
scaling, Assuring, and furrowing are common ; and the accu- 

Fig. 29. 




Elephantiasis of the foot and leg. 



mulation of altered sweat and sebum in these depressions is the 
source of an offensive stench. During the course of the disease 
almost all of the elementary lesions of the skin may be dis- 
played by the skin, maculae, vesicles, papules, tubercles, pustules, 
blebs, ulcers, crusts, scales, excoriations, and fissures. Warty 
growths form as large as those seen in icthyosis hystrix ; and in 
some cases, reddish colored tumors spring from the hypertrophied 
integument. 

When fully developed in the lower extremity, the unwieldy 
limb with the foot, ankle, and leg massed into one huge, cum- 
brous cylinder, bears a striking resemblance to that of the 
elephant, from which circumstance the malady first received its 
name among the Arabs. Locomotion is then greatly impeded, or 
rendered impossible. No less striking is the similar deformity 
induced in the female labia or male scrotum, the latter at 
times hanging far below the knees. In its rugous folds the 
penis disappears, and the urine is passed along a gutter formed 
of skin transformed into quasi-mucous membrane. As a conse- 
quence of the fissures and excoriations which form, the lym- 
phatic channels are finally opened, and a true lymphorrhcea re- 
sults. From similar processes the ear may become largely pen- 
dulous by the side of the neck. 



248 DISK ASKS OF THE SKI.V. 

Subjectively, the disease may be regarded as productive of less 
discomfort than would be suggested by its formidable features. 
Pain is occasionally experienced, and, during t lie exacerbations, 
accompanied by pyrexia, there is corresponding malaise. The 
chief subjective Bensationa arc those induced hy the weight and 
consequent tension, inseparable from the enormous masses of 
hypertrophied tissue. 

Etiology. — The causes of elephantiasis are exceedingly ob- 
scure. Predisposition of races or individuals, heredity, climatic 
influences, malaria, fatiguing labor, with the feet and lesrs im- 
mersed in water and filth, in connection with "misery," have 
all been cited as favoring conditions. To these should be added 
the local disorders, especially common in the lower extremities, 
which have in cases proved to be the points of departure of the 
elephantiasic hypertrophy, such as obstruction to the nervous 
or lymphatic currents by pressure of tumors, pregnancy, or 
neoplasms; ulcers, cicatrices, and the presence in the blood of 
the jilaria sanguinis hominis. 

Pathology. — Even macroscopically, the elephantiasic mass is 
seen to be built up of hypertrophic elements representing all the 
tissues of which the part is composed. The knife with diffi- 
culty divides the homogeneous, whitish, and lardaceous mass, 
from which on pressure exudes a fluid of similar color. The 
subcutaneous, connective tissue is found relatively much more 
enlarged and sclerosed than the epidermis and derma; though 
when the section is made through the rugous and warty skin 
described above, all the elements of the papillary layer, rete, and 
stratum corneum are seen to participate in the changes de- 
scribed in connection with the pathology of verrucca. Here and 
there are loculi filled with a fluid lymph. The sheaths of the 
bloodvessels, lymphatics, and nerves, the bones, muscles, and 
aponeuroses are also thickened, solidified, and occasionally ag- 
glutinated, so as to be almost indistinguishable in the mass of 
uniformly sclerosed tissue. The pigmentation of the derma is 
marked ; the so-called nuclei of the connective-tissue elements 
are multiplied, and the cutaneous glands intact, hypertrophied 
in the epithelial linings and investments ; or, at a later stage, 
atrophied. 

Diagnosis. — The striking deformity, which characterizes ele- 
phantiasis, will always suffice for its recognition. In the earliest 
stages of the disease, when merely an erysipelatous or eczema- 
tons condition of the skin can be determined, it would be diffi- 
cult, if not impossible, to decide as to the future of the disor- 
der, especially in a locality where only sporadic cases occur. A 
symmetrical hypertrophy of both legs and both feet developing 
in this country, even though described as " elephantiasis," should 
be most carefully studied before a diagnosis is made of the par- 
ticular disease here considered. The same might even be said of 
elephantiasis of but one inferior extremity. I was once re- 



ELEPHANTIASIS. 249 

quested to examine a patient with extensive deforming indura- 
tion and enlargement of the right leg and foot, accompanied by 
pigmentation and a well-marked warty condition of the skin, 
who had been pronounced to be the victim of idiopathic ele- 
phantiasis Arabum. It was discovered that the patient had 
had a fracture of the upper third of both bones of the same leg 
during the previous year, and had since constantly worn a tight 
bandage, encircling the limb at the seat of the injury. The 
deformit} 7 rapidly disappeared under the application of a roller 
bandage extending from the toes upward. 

Treatment. — In the early stages of elephantiasis, the febrile 
condition of the patient and the localized cutaneous inflamma- 
tions, are to be treated by the measures appropriate for the re- 
lief of these conditions. Quinine, especially in malarial districts, 
is of the highest importance. When the elephantiasic develop- 
ment is established, if the genitals are involved, the knife of the 
surgeon offers the best prospects. The result of such interference, 
both in the genitalia and extremities, has been in many cases 
brilliant indeed, though the mortality of such severe operations 
is necessarily great. When the lower extremity is involved, it 
should be maintained in a horizontal position, its ulcers if pos- 
sible healed, its excrescences removed, its circumscribed inflam- 
mations resolved, and. then elastic compression be carefully and 
skilfully sustained by means of the rubber bandage. The toes 
are first separately enveloped ; then the foot and ankle : and 
lastlj T the leg. The results are sometimes highly satisfactory. 

Ligation and digital compression of the main artery supplying 
the elephantiasic leg, have been occasionally followed by tran- 
sient improvement. Instrumental compression has at times re- 
sulted in severe ulceration, and a reawakening of the erysipela- 
tous affection. Multiple punctures and incisions, made with a 
view to giving exit to the fluids contained in the mass, have 
been attended by no greater success. The main obstacle in all 
these surgical procedures, is the lymphangitis which so frequently 
complicates the situation. None of them promises so well as 
nerve-stretching, which, in a few isolated cases, has been fol- 
lowed by noteworthy results. Elastic compression in the hori- 
zontal position for all cases not warranting nerve-stretching, may 
be regarded as the wisest course when the extremity is involved. 
For the local treatment of the pachydermia proper, green-soap, 
mercurial ointment, and bathing in hot or cold lotions, may be 
advantageously employed. For patients whose disease is ac- 
quired in countries where the deformity is prevalent, a change 
of climate is of the highest importance ; and, having in view the 
social surroundings and habits of most victims of the disease, it 
is scarcely necessary to call attention to the need of a proper 
hygiene, diet, and tonic regimen. 

Prognosis. — The future of a patient affected with the disease 
may be regarded as most favorable when the latter exhibits an 
early tendency to respond favorably to appropriate treatment, 



250 DISEASES OF THE SKIN. 

and when circumstances permit of a resort to the best thera- 
peutic measures which can be adopted, such as change of resi- 
dence, persistent and careful dressing of the affected part, and 
the removal of any exciting cause of the disease, such as a neo- 
plasm, indurated cicatrix, etc. In the severer cases, a fatal re- 
sult may he precipitated ; but usually life is prolonged, burdened 
by the inconvenience of the enormous elephantiasic mass in com- 
parison with which the rest of the body often seems to serve as 
a mere appendage. 

Dermatolysis. 

Deris. Gr. ii'fxa. the skin ; and Xt?«c, laxity. 

Dermatolysis is an hypertrophicd condition of the skin with its underlying pan- 
nicuhis adiposus, muscles, and bloodvessels, in consequence of which pendu- 
lous tumors or folds are formed, in a soft turgescent, compressible, or firm 
state. 

Symptomatology. — This is even rarer of occurrence than ele- 
phantiasis. It consists of a circumscribed hypertrophy of all 
parts of the skin, often including the subcutaneous tissues, mus- 
cles, and a plexus of vascular elements, forming largely pendu- 
lous folds about the eyebrows, face, neck, shoulders, genitals, 
extremities, and belly. There is evident hypertrophy of all 
parts composing the growth, the skin over which is either natu- 
ral in softness, texture, and appearance; or is roughened, and 
exhibits a peculiar distinctness of its visible prominences and 
depressions. At times, as in the case seen by Kaposi, the com- 
ponents of the tumor or fold are as compressible as a sponge, in 
consequence of the vascular plexus it contains. For this reason 
it is described by that author under the title elephantiasis telan- 
giectodes. The tumor may he insensitive and slight, or produc- 
tive of a sense of tension from its weight; or be actually pain- 
ful, from the existence of neuromata in its mass (Czerny). 

The masses thus formed are occasionally of very extensive 
development. Duhring, who had the opportunity of studying 
Weeden Cooke's case, describes four or live overlapping folds of 
hypertrophied integument falling from the left hip of a young 
girl, to the knee, each capable of being separately lifted. The 
only case which I have had the opportunity of observing was 
that of a twelve-year-old child, affected also with disease of the 
hip-joint. She exhibited a pendulous mass as large as a platter 
depending from the left shoulder. It could be carried with ease 
away from the trunk upon which it naturally rested, and repre- 
sented merely a double-fold of hypertrophied integument be- 
tween which seemed to be interposed a layer of adipose tissue 
of moderate thickness. Dr. Piffard, 1 of New York, lately ex- 
hibited at the Medical Department of the University, a remark- 
able case of dermatolysis, the man having been also the subject 

1 N. Y. Med. Kecord, April 1, 1882, p. 364. 



SCLEREMA NEONATORUM. 251 

of some observation and study at Vienna. There, it was ascer- 
tained that the integument was unchanged, except in so far as the 
lack of an abundant panniculus adiposus permitted extraordinary 
movement of the skin over the parts which it covered. In this 
case, the integument could be drawn out to the extent of five or 
six times the normal distance. 

The pendulous mammas and bellies of both very lean and very 
fleshy individuals which have been described as cases of dermato- 
lysis, would seem to belong to another category. There is here 
rather a laxity with atrophy, than the reverse. I have seen a 
naked n egress in Africa suckling the child upon her back, with 
her long, narrow, lax, and conical breast brought up over the 
point of her shoulder, but should be unwilling to describe such 
a condition, evidently the result of confirmed habit, as an in- 
stance of dermatolysis. 

Pathology. — Some confusion seems to exist with regard to the 
condition here considered. The term, dermatolysis, should be 
limited to the distinctly circumscribed hypertrophous growths 
of the skin and subcutaneous tissues which form pendulous 
masses. It is evident, however, that cases of fibroma, telan- 
giectasis, and even of laxness of the skin induced by muscular 
atrophy, have been described under this title. 

Etiology, Diagnosis, Treatment, and Prognosis. — The causes of 
the disease are unknown. There is some reason to believe that 
it is, in cases at least, hereditary; as it has been observed in one 
family in three successive generations. In some instances, it is 
recognized as a congenital deformity. The diagnosis is between 
fibroma and lipoma, with which it may indeed concur. In the 
former case, there is a much greater tendency to pedunculation 
of the mass and to multiplicity of lesions; in the latter, the 
characteristic "cushiony" feel of the part, and the absence of 
cutaneous hypertrophy, will aid in determining the nature of 
the growth. Treatment, where any is indicated, necessitates 
usually the ablation of the mass. An operation with this end 
in view was performed some years ago in this city in the ease 
of a female patient whom I never saw, affected with a large 
hypertrophous fold, depending over the genitals. The result was 
fatal. The prognosis of each case rests upon the benign charac- 
ter of the growth.' 

Sclerema Neonatorum. 

Deriv. Gr. c-xx»po?, hard. 

Sclerema Neonatorum is a disease of early infancy, induced by changes in the 
capillary circulation, accompanied by a progressive fall of temperature, and 
characterized by blanching, oedema, and even mummification of the skin. 

Symptoms. — The disease occurs, as a rule, soon after birth, and 
is displayed in a progressive cooling of the surface of the body, 
with an increasing; and extending; oedema, first most noticeable 



252 DISEASES OF THE SKIN. 

in the lower extremities. Tlie skin is blanched, marbled, mot- 
tled, or more rarely of a yellowish, reddish, or violaceous hue, 

pits upon pressure, and later is indurated, firm, tense, and shining. 
The condition becomes more or less rapidly noticeable over the 
other parts of the body, the face, upper extremities, and trunk. 
As a consequence, motion is impeded, the features are stiffened, 
suction of the nipple is rendered difficult or impossible, and the 
infant reclines helpless, motionless, rigid, and cold to the touch, 
displaying the signs of a waning vitality merely by its moans 
and superficial respiration. Death usually occurs within a brief 
time. 

The respiratory and circulatory systems are in such cases 
always at fault. The disorder is common after capillary bron- 
chitis, the pneumonia of infants, and the gastro-intestinal dis- 
orders which prevail in premature, imperfectly nourished, and 
neglected infants of a tender age. 

Etiology. — The causes of the disease, whose cutaneous mani- 
festations I believe to be purely symptomatic, are to be sought 
in every systemic disorder of early infancy which is accompanied 
by retardation of the respiration and circulation. I have for 
several years past been in position to observe the changes which 
precede a fatal issue in a large proportion of the abandoned and 
diseased foundlings cared for in the infirmary of the Chicago 
Home for the Friendless, and in several such have distinguished 
unmistakable symptoms of sclerema neonatorum. Three of these 
had been, significantly, abandoned at the door of the institution 
in very cold weather, and had there remained for several hours 
exposed and unnoticed. In none was it necessary to seek for 
causes any more profound than those which the history of each 
case suggested. 

Pathology. — Post mortem, there is discovered no hypertrophy 
of the cutaneous elements. The tissues are simply distended 
with serum, in other words cedematous. This fluid flows forth 
after incision of the parts, more or less stained by the coloring 
matters of the blood, which was during life in a state of partial 
stasis. The stearine-like deposit found in the panniculus adi- 
posus, is merely coagulated lymph whose movement, has been 
arrested and whose temperature lias been lowered simultaneously 
with that of the blood. 

Diagnosis. — The disease is readily recognized by its charac- 
teristic features exhibited in very early infancy, and in subjects 
suffering from any cause which strongly depresses the respira- 
tory and circulatory activity. It is to be distinguished from 
sclerema adultorum in which there is a hide-hound condition 
of the integument, of very slow progress and rarely generalized. 
The latter disease is due to a true hypertrophy of the cutaneous 
elements. 

IVeatment. — The treatment should be exclusively directed to 
the restoration of the warmth, the stimulation of the respiratory 



SCLERODERMA. 253 

and circulatory centres, and the proper alimentation of the little 
patient. Massage and cutaneous frictions with artificial heat 
applied externally, are serviceable. The prognosis is grave. 
Infants are said to have been saved after exhibiting these symp- 
toms. I have seen none such recover. 



Scleroderma. 

Deriv. Gr. c-a^po?, hard ; Ss ?/ ua, the skin. 

Scleroderma is a chronic affection, characterized by a circumscribed or rela- 
tively diffuse induration, rigidity, fixation, and subsequent atrophy of the 
skin, the affected parts being yellowish-white, waxy, or pigmented in color,, 
and either elevated or depressed, the disease-process enduring for a series 
of years, and, in certain cases, terminating fatally after the induction of 
marasmus. 

Symptomatology. — The disease is first manifested in irregularly 
defined coin or palm-sized patches, in elevated or depressed rib- 
bon-like bands, or in a more extensive and uniform involvement 
of the skin, usually that of some part of the upper segment of 
the body. The affected areas in either of the forms named may 
be elevated slightly above the level of the adjacent normal in- 
tegument, or to an equal extent depressed below it, or both; the 
depressions being irregularly distributed among the elevations, 
or, especially in the ribbon-like form, bordered on either side by 
dense ridges. In all fully-developed cases, the most prominent 
feature is the sclerosis, the skin being indurated, brawny, tense, 
and immovable upon, because adherent to, its underlying struc- 
tures, as the muscles, aponeuroses, and periosteum. 

For this reason there is at times interference with the move- 
ments of the trunk in respiration, as also of the lips and other 
parts of the face in the expression of the emotions, and of the 
fingers in the grasp of the hand. The disease, in short, produces 
the condition often described as " hide-bound." The skin of the 
aifected parts is usually yellowish-white, dirty yellowish, waxy, 
or alabaster in color; is often slightly desquamating, and may 
be pigmented in various shades from yellow to brown and bronze. 
There is usually no alteration in the subjective sensations, tem- 
perature, glandular secretion, nor, in the early stages of the dis- 
ease, in the general health of the patient. The malady begins 
insidiously but may, however, be rapid in its development and 
accompanied by pyrexic or rheumatoid symptoms. In its sub- 
sequent progress it always pursues a chronic course. 

That progress may be either toward definite resolution, per- 
sistent cutaneous atrophy, or the final induction of a fatal maras- 
mus. But little is known of the concluding stage of the affec- 
tion, patients before arriving at that term usually drifting from 
the observation of practitioners. Nearly twenty fatal cases are, 
however, on record. The skin may be entirely restored to its 



254 DISEASES OF THE SKIN. 

normal condition,. but often such restoration is succeeded by a 
return of tlie disease in the part originally affected, and by the 
involvement of new areas. 

The sites usually involved are the head, trunk, and upper 
extremities, including the mamma of the female. It is occa- 
sionally of symmetrica] development. When occurring; upon 
the face an exceedingly characteristic symptom is the resulting 
immobility of the features. 

Its lesions are accompanied at times by other cutaneous dis- 
orders, such as eczema, erysipelas, melanoderma, anidrosis, mor- 
phoea, zoster, and acne. 

Exaggerated forms of the disease have been noted by several 
authors, where, to a varying extent, the surface of the lateral half 
of the face has been involved, the resulting condition being 
described as iiemiatrophia facialis. Here not only the subcu- 
taneous tissue, but. the aponeuroses, periosteum, and bones may 
participate in the atrophy, a fact well illustrated in the case of 
Robinson's patient, 1 whom I had the opportunity of examining. 
In this instance there was also a distinct sclerodermatous lesion 
on the face of one thigh. 

Scleroderma is exceedingly rare; and I have endeavored in 
the preceding description to be guided largely by the notes of 
the few cases which I have had under my observation, five in 
all. In one male patient the surface of the entire chest was 
symmetrically involved to the extent of inducing marked dys- 
pnoea, and the general condition was that of decided asthenia. 
His skin was tightly bound in undulating ridges to the ribs 
beneath, and colored in a dirty-yellowish shade. The other 
patients were much less seriously affected ; one had symmetrical 
scleroderma of a part of the front of the thorax in irregular 
patches; another, a band-like deep yellow depression between 
dense ridges which fastened that part of the forehead firmly to 
the frontal bone; the fourth, a limited whitish patch at the 
back of the neck; and the fifth, a diffuse scleroderma of the 
cutaneous envelope of the left mamma, the patient dying in a 
neighboring State one year after my examination of her person, 
of what, her physicians pronounced to be "sarcoma" of the lung. 

Etiology. — The causes of the disease are unknown. It is ob- 
served in about two-thirds of all cases in the female sex, a fact 
which certainly points to some other cause than rheumatism as 
effective in its production, since men are more exposed than 
women to the changes in atmospheric temperature and humid- 
ity, which are generally admitted to have an etiological import- 
ance in rheumatism. The disease occurs at all ages, chiefly, 
however, in adults. Cruse observed one case in a child two 
years old. 

Pathology. — The confusion which has existed in relation to the 

1 Amer. Journ. of the Medical Sciences, Oct. 1878. 



SCLERODERMA. 255 

question of the identity of scleroderma as distinguished from 
morphcea is due to several causes. The two affections, if they 
be such, are designated by several authors under each of the two 
names; and the symptoms here described as peculiar to each are 
occasionally seen either simultaneously or successively in the 
same individual, being then coincidences of separate disorders, 
or different manifestations of one only. I have chosen to follow 
the somewhat provisional distinction established between them 
by Sir Erasmus Wilson, Fox, and Duhring, chiefly for the reason 
that my clinical experience of the two, however limited, has fully 
justified such a course. The cases of morphcea observed and 
somewhat carefully studied by myself, have all presented dis- 
tinctly different symptoms from those of scleroderma described 
above. 

Microscopical examination of the tissues involved in the dis- 
ease has proved unsatisfactory. The connective tissue of the 
skin has been found, according to Kaposi, condensed and thick- 
ened . ; its elastic fibres multiplied at the expense of the pannic- 
ulus adiposus; its muscular tissue hypertrophied ; the pigment 
in the rete and corium increased ; the sweat glands dilated; the 
lumen of the bloodvessels diminished, and their walls ensheathed 
in accumulations of what he terms u lymphatic cells." 

Diagnosis. — In order to establish a differential diagnosis be- 
tween scleroderma and morphoea, it will usually he sufficient to 
observe the peculiarities which are admirably contrasted by 
Duhring, and which, with some modification, may be concisely 
stated as follows: — 

Scleroderma is occasionally symmetrical, usually insidiously 
developed, void of subjective sensations, and indeterminate in 
outline. Morphoea is usually asymmetrical, often accompanied 
by pain or tingling, and exhibits a particularly well-defined 
contour. Scleroderma may affect large areas of the integument 
which are at some time densely rigid and firm, and may not ex- 
hibit to the eye a structural change. Morphcea is of much less 
extensive development, produces a soft, somewhat elastic or 
"cushiony" feel to the touch, and alters the skin so that the 
eye can take cognizance of the change. The former commences 
as a cutaneous sclerosis ; the latter as a patch of altered color, 
the change of hue being due to a greater or less degree of vascu- 
larity. Lastly, in scleroderma there is no telangiectasis, nor 
punctate atrophy. 

Treatment. — The treatment of scleroderma, though empirical, 
should be persistently enforced in the hope of improvement. 
Locally, baths (cold, hot, sea, vapor, Russian), massage, frictions 
with fat and oils, and possibly the hypodermic injection of pilo- 
carpine (Besnier, Doyon) may be advantageously tried. The 
inunction of mercurial and iodized unguents has proved futile. 
Internally, quinine, iron and arsenic, cod-liver oil, and the usual 
hygienic and tonic regimen, are severally indicated in different 
cases. 



256 DISEASES OF THE SKIN. 

Prognosis. — The outlook for the patient affected with exten- 
tensive scleroderma, especially of the trunk, is decidedly unfa- 
vorable. Much more limited expressions of the disease may he 
regarded as less grave. Recovery in cases is said to have been 
perfect Atrophy once established, is final. Contracture of 
mouth, fingers, or costal region, may prove serious. Patients 
yielding to" marasmus are naturally those to whom little can he 
promised. Even after slight manifestations of the disease, the 
future may he portentous. 

Morphoea. 

Dcriv. Gr. fAtpfh. by metathesis, form. 
Morphoea is a cutaneous disease characterized by the occurrence of one or seve- 
ral discrete, well denned, firm and smooth points, patches, lines, or bauds, 
often slightly elevated or depressed, and surrounded by a delicate violaceous 
or lilac-tinted halo, whose involution may be followed by macular, punctate, 
or striate, atrophy of the skin. 

Symptomatology. — This disease, once known under the mis- 
leading title of "Addison's Keloid," occupies to-day a precarious 
position in the list of cutaneous maladies. By some authors it 
is not recognized as a distinct affection, and occurring, as it may, 
in the person of patients who are subjects of scleroderma, it is 
by the former regarded either as a stage or possible mode of 
evolution of that disease. Perhaps no better basis for the recog- 
nition of its identity as a distinct affection can be furnished, 
than a brief description of the most perfect specimen of the dis- 
ease I have observed. 

The patient, sent to me by one of my colleagues, was a vigor- 
ous, well-nourished, sixteen-year-old girl, with a patch upon the 
outer face of the left thigh, as large as a breakfast plate, and 
almost as perfectly circular. It was slightly elevated in its cen- 
tre above the adjacent level, and thence declined to the periphery 
by a gentle curve, quite perceptible when viewed from the side. 
It was firm but not indurated, feeling to the linger like a densely- 
padded cushion set in the skin. With some difficulty it could 
be gathered up between the lingers. Sensibility was slightly 
impaired over its surface. Its outline was so distinct that its 
limits could have been traced by a pen. The surface was ex- 
ceedingly smooth, and colored in a shade between alabaster and 
yellowTsh wax. Regularly dispersed over the surface of this 
circular cushion, were discrete, slightly pigmented, atrophic 
puncta, separated slightly from each other by an inch or less 
of the shining substance constituting the patch. About it was 
a delicate, elegant, and very regularly displayed halo of a vio- 
laceous tint, which on close inspection could be seen to be pro- 
duced by a plexus of minute capillaries. 

Of the few cases of this rare disease which I have had the for- 
tune to see, no one was comparable with that described above, 



MORPHGEA. 257 

either in size or in the perfection of its features; yet all were 
readily distinguished from, and actually uncomplicated by, scle- 
roderma. Other forms in which the disease is manifested are one 
or more coin- to palm-sized patches approximately circular, either 
at the general level of the integument or slightly depressed be- 
low it, the tissues in which are either natural, or unusually firm, 
tense, and suggestive of a tightly stuffed cushion. The surface 
may be rosy-pink, whitish, yellowish, lardaceous, purplish, mot- 
tled, or pigmented. It may resemble marble, alabaster, wax, 
bacon, or a piece of tanned leather. Occasionally there is super- 
ficial desquamation. Often minute bloodvessels ramify over 
its surface, or in the areola, beyond which also the skin may 
be pigmented in various shades. The centre is often partly 
anaesthetic. After existing for months and even years, these 
lesions may undergo involution, leaving an unaltered integu- 
ment where they once existed, or, more commonly, a contracting 
cicatriform atrophy of the skin and often also of the subcuta- 
neous tissues, the resulting scar becoming agglutinated to the 
structures lying beneath it. 

The lesions may also often be first observed as punctate or 
striate atrophic depressions. An exaggerated form of the latter 
is the more or less broad, grooved streak, or furrow, in the 
sunken floor of which is a glazed, white, firmly attached, and 
insensitive epidermis, bounded on either side by hyperaemic, pig- 
mented, or otherwise altered smooth edges or ridges. Whether, 
however, in the form of patches, puncta, strise, furrows, or broad 
grooves, these changes must in many cases be sequelae of the 
insidious deposition of lardaceous material to a corresponding 
extent, whose resorption lias been unnoticed. As in the case 
of striae et maculas atrophica^, many of these lesions are mingled 
with, or surrounded by, variously colored, pigmented, hypera;inic 
or telangiectasic patches, streaks, lines, or mere shadows. Often 
a delicate, yellowish, or violaceous streak, can be distinguished 
in the immediate proximity of these curious lesions, and the 
most careful scrutiny w T ill fail to define either its outline or 
character. 

The disease occurs asymmetrical^, and often unilaterally, upon 
the face, back of the neck, surface of the trunk, including the 
female breast, the belly, the arms, and the thighs. It is said, 
also, at times to select the areas supplied by certain nerves, a 
feature by no means distinctive of the disease. Tilbury Fox, 
for example, writes that, " when morphcea occurs on the fore- 
head, it takes the course of the supraorbital nerve;" but I have 
certainly seen one perfect frontal groove, with pigmented, yellow- 
ish edges, terminating fully an inch from the supraorbital notch. 

Etiology. — The causes of the disease are unknown. It rarely 

occurs in males, a large proportion of all patients being females. 

I have, however, seen an oval patch two inches in length upon 

the back of the neck of a young man. All of my patients were 

17 



208 DISEASES OF THE SKIN. 

individuals in early adult life, though it is said to occur at all 

ages. The subjects of the disease are both vigorous and weakly. 

Pathology. — The Btudies thus tar made of the microscopical 

anatomy of the disease have neither sufficed to demonstrate its 
identity as distinguished from scleroderma, nor to explain sat- 
isfactorily the polymorphism of the affection. Duhring, in one 
ease, established shrinkage of the upper and condensation of the 

lower layers of the corium; while Crocker, 1 besides noting the 
usual phenomena of multiplication of the elements of the derma 
and secondary changes in the rete and skin "lands, thought there 
was also a fibrous metamorphosis of the protoplasm, confirming 
thus the view of Fox, that the disease is essentially a fibroid 
degeneration of the skin. It is possible that the disease may he 
eventually shown to have, as Hutchinson and others believe, a 
neurotic origin; but certainly its occasional appearance in the 
areas supplied by special nerves is by no means peculiar to it ; as 
various pigmentary moles, warts, and other lesions, whose patho- 
logical anatomy is better understood, often confess their subjec- 
tion to the same influence. Of the speculative theories sug- 
gested in explanation, I should prefer to believe that the singu- 
lar changes observed were originally due to lymph-stasis follow- 
ing local perversion of nutrition. 

Diagnosis. — For the distinctive differences between morphoea 
and scleroderma, when such are recognizable, the reader is re- 
ferred to the details presented in connection with the diagnosis 
of the last-named disease. From the patches of vitiligo those 
of morphoea are readily distinguished by the entire absence of 
all structural cutaneous changes in the former, and their charac- 
teristic milky-white color, the hairs of the part being also 
blanched. Both the pigmented macules and atrophic patches of 
lepra are remarkable for their anesthetic condition, and their 
coincidence with, or sequence from, other readily recognized 
symptoms of the disease, such as tubercles, bullae, ulcers, and 
involvement of the hairs, nails, eyes, and other organs. 

Treatment — In many of the milder cases of morphoea, espe- 
cially those existing upon portions of the surface concealed by 
the clothing, there is no indication for treatment. The patient's 
general health is unimpaired, and the local disorder unproduc- 
tive of either present discomfort or a menace for the future. 
"When the disorder is facial, and atrophy has already occurred, 
the resulting disfigurement may be regarded as remediless. For 
the earlier stages of the disease upon the face, and for those lesions 
in other situations which, from their size, number, or progress, 
are portentous, general and local treatment may be required. 
The former includes the use of iron, quinine, arsenic, cod-liver 
oil, strychnia, and phosphorus, with the usual roborant regimen 
and diet. The latter involves the application of the various 

» Lancet, November 22, 1879. 



ATROPHIA CUTIS. 259 

simple stimulants, frictions with oil, spirits, and soaps, singly 
or in combination ; lotions with the mercuric bichloride, and 
massage. In pregnant women treatment should be deterred till 
after delivery, when involution may be more speedily obtained. 
Young girls, chlorotic, anaemic, and suffering from menstrual 
derangements, should be taken from the school-desk and the 
piano-stool, and sent to the riding-gallery, the gymnasium, or 
the dairy-farm, where they can swallow a goblet full of pure, 
fresh milk after each meal. 

Prognosis. — The disease may terminate by spontaneous and 
perfect restoration of the part. Adherent atrophic striae or 
patches are remediless. The progress of the disease is exceed- 
ingly indolent, and may continue for a lifetime. Occasionally 
grave sequelae may be anticipated. 



4. Atrophic. 

Atrophia Cutis. 

Deriv. Gr. a., privitive ; and Tpos>h, nutrition. 

Atrophy of the skin is an idiopathic or symptomatic, diffuse or partial, diniinu- ■ 
tion of the mass of the integument, or its reduction, by loss or degeneration 
of one or more of its histological elements. 

The skin and its appendages, in common with the other organs 
of the body, may suffer from atrophy, either idiopathic or symp- 
tomatic in character, and general or partial in extent. It may 
result from either quantitative or qualitative, retrogressive 
changes, losing thus its normal dimensions, either from wasting 
of one or all of its normal elements, or from degenerative 
changes in the latter, or from their complete and final disap- 
pearance. Naturally these changes may be simultaneous. They 
are usually effected slowly, and the results are persistent. They 
are frequent concomitants of a long list of other pathological 
alterations. Usually, however, they succeed the latter. Under 
the general title of atrophy of the skin several rare forms of the 
disease have been considered. 

Xeroderma. 

{Deriv. Gr, £«?o?, dry ; and M^a, the integument. ) 

This term has been employed in the designation of several 
cutaneous disorders which differ in their pathological signifi- 
cance, but which are alike chiefly characterized by a dry and 
parched condition of the surface, including asteatosis, and the 
less pronounced forms of ichthyosis. In these pages the name 
is applied exclusively to the disease known as the " parchment- 
skin," or xeroderma, of Hebra. 

But few cases have been recorded, and these by Kaposi, Glax, 



260 DISEASES OF THE SKIN'. 

and Geber, abroad ; and, in this country, by Taylor, of Xew 
York, in ;m interesting series of seven eases, and by Duhring, of 
Philadelphia. The disease results ultimately in a diffuse idio- 
pathic cutaneous atrophy, but this condition is preceded by a 
general hyperemia with vascular dilatation, and the production 
of numerous, punctiform, bright-red telangiectases and dissemi- 
nated, brownish and yellowish-brown maculae, varying in extent, 
between which form superficial, whitish and glossy, atrophic de- 
pressions, like the cicatrices of variola. The skin becomes fur- 
rowed, contracted, and as dry as parchment; and thus is readily 
developed an eczema or a superficial degeneration, including ul- 
ceration. A species of furfuraceous desquamation also occurs in 
patches. The faces of most patients exhibit a peculiar checkered 
appearance, from the uniform dissemination over the skin of 
the pigmented maculae. Ectropion, with ulcerative keratitis, 
epitheliomatous, sarco-carcinomatous and angio-myxornatous 
growths complicated several of the cases reported ; and in two, 
certainly, were the immediate causes of a fatal issue. Often, 
however, the general health seems, for long periods of time, to 
remain unimpaired, the subjective sensations being slight. Ob- 
servers of these cases differ somewhat as to the order in which 
the several lesions of the disease appear; and Duhring thinks it 
possible that no definite order is observed in the evolution of 
the symptoms. The etiology, pathology, and appropriate treat- 
ment of the affection are not understood. 

Blanching Atrophy of the Skin. 

Several instances of this peculiar degeneration of the integu- 
ment have been observed. It is characterized by an unnatural 
whiteness or pallor of the surface, with considerable tension and 
tenuity of the epidermis, usually limited to the extremities 
(the arms and palmar faces, ami the thighs and legs and plantar 
faces), moderate exfoliation occurs; and the latter, in connection 
with the tension to which the skin is subjected, is responsible 
for more or less painful subjective sensations. The disorder is 
chronic in its course, and may originate in infancy. 

The purest type of this atrophy is encountered in a well-nour- 
ished individual, one of whose limbs has long been affected with 
sensori-motor paralysis. The muscles waste, while the fatty 
elements may either persist, multiply, or almost wholly disap- 
pear. Over the whole rests a soft unusually whitened integu- 
ment, which in the paralysis of the aged often suggests the deli- 
cacy of childhood. Its hairs are relatively few; its pigment 
scanty; and its bulk manifestly diminished. In other cases, 
however, where there is trophic disturbance, the skin undergoes 
a shrivelling, with dirty yellowish coloration, and the exfoliation 
of dry epidermal plates. In these retrogressive changes, the 
nails may participate. 



STRIDE ET MACULE ATROPHICA. 261 

The "glossy fingers," described by Sir James Paget, 1 are 
probably of the same general character. They are "tapering, 
smooth, hairless, unwrinkled, glossy, pink, and ruddy, or blotched, 
as if with permanent chilblains." One or several fingers are 
affected. The condition is associated with neuralgia or nervous 
impairment. 

Atrophia Senilis. 

This is the frequently recognized cutaneous degeneration pecu- 
liar to old age. The skin becomes colored in various shades of 
brown, either uniformly or in tolerably distinct maeulations over 
the face, dorsum of the bands, the genitalia and the anus, and. 
the lower extremities. It is seamed with furrows and wrinkles, 
often in various degrees desquamates slightly, and, losing the 
cushion of fat upon which it rested in earlier life, is either 
readily raised from the subcutaneous structures, or depends from 
them in loose folds. Pea- to finger-nail sized, verruciform, dirty- 
yellowish accumulations of epidermis become visible, often in 
numbers on the face and elsewhere, extending either as far as 
the deeper portions of the horny layer or the rete. 

The cutaneous atrophy in such cases may be characterized by 
unusual dryness, with failure of reproduction of the elements of 
the skin after the loss by physiological waste. The epidermis 
and derma, by their shrivelling, lose largely their characteristic 
interdigitations, while the elements of which they are composed, 
are impoverished in protoplasm. Vessels, relatively numerous 
before, disappear; pigment multiplies; the hairs are either pro- 
duced as lanugo, or fall as the papillae in the fundus of their 
sacs flatten; the root-sheaths encroach upon the follicle; while 
the sebaceous and sweat glands may either disappear or dilate 
and become filled with an epidermic detritus. 

In other cases the skin elements undergo a true metamorpho- 
sis, fatty, lardaceous, amyloid, colloid, waxy or vitreous. 

Striae et Maculae Atrophicse. 

Partial idiopathic atrophy of the skin occurs most frequently 
in linear cicatriform striae or streaks, an inch or more in length, 
developed chiefly about the hips, buttocks, and upper portion of 
the thighs in both sexes of adult years. Less frequently they 
are observed upon the neck, trunk, and extremities. They are 
insidious of development, indelibly persistent, and appear as 
sensibly thinned, glistening, and often depressed lines or fur- 
rows, having a whitish hue, with an occasional blending of a 
very delicate purplish tint. They are usually multiple, and at 
times abundantly displayed, running in various curves, for the 
most part parallel with the long axis of the body. They occa- 
sion no subjective sensation, and their etiology is unknown. 

1 Med. Times and Gazette, March 26, 1864. 



262 DISEASES OF THE SKIN. 

Much more rarely the atrophic areas occur in macular patches. 
Tlie lesions arc then fewer, more isolated, and are discovered 
more frequently upon the extremities, but also on the trunk, 
varying in size from a coftee-bean to a chestnut. This form of 
atrophy often succeeds cither an erythematous or pigmented 
condition, which very slowly changes till there is formed the 
dead-white, round or oval, often insensitive patch, resembling 
coarsely a vaccine cicatrix. Taylor, 1 and Atkinson, 2 have de- 
scribed some v<.-vy interest ing feat ures in this process; and I have 
been able to verify the accuracy of their ohservations in the only 
two cases of the affection I have had the opportunity of study ing. 
In both, the lesions occurred about the ankles of women with 
menstrual derangements, the largest spot of all attaining thesizeof 
the transverse section of a hen's egg. The patches were in various 
degrees insensitive, very slightly depressed, smooth, glistening, 
and scar-like, the condition being the sequel of brown- to choco- 
late tinted pigmentations, limited to the spaces which become 
afterward atrophic. Cantani 3 describes similar atrophic macula?, 
where there had been a bluish red color, evidently due to the 
development of minute vascular capillaries. The sensibility of 
the skin Avas unaltered. Under the microscope both the linear 
and macular lesions show separation of the fibrous fasciculi, 
effacement of the papillary layer of the corium, and diminution 
in the number of vessels and glandular appendages. In Taylor's 
and my cases, the macula? were quite hairless; in Atkinson's 
the hairs were relatively few 7 in number. 

Ftfre" ami Quemonne 4 have also described two singular cases 
observed in Charcot's clinic. In one of these, minute, whitish, 
elongated cicatrices appeared, about which there was marked 
pigmentation of the skin. They were abundant in the lumbar 
region. In a second case, brownish lines appeared over the 
hreasts of an unmarried woman which gradually grew paler, 
while others appeared over the skin of the throat. Those which 
were recent had a brownish or bluish-red color; others were of 
a dead white hue ; some appeared over the lumbar region and 
the upper part of the buttocks ; but there were none over the 
belly, the groins, and the thighs. In both cases the regions 
attacked were those in which there was no suspicion that the 
vergetures resulted from overdistension of the skin. 

These lesions are to be distinguished from the sequela? of 
morphcea, syphilis, and other diseases capable of leaving atrophic 
areas. A previous history of such pathological conditions would 
usually be needful ; but in the cases where there is precedent 
telangiectasis, hyperemia, or marked pigmentation of the spot, 
the diagnosis from morphcea will be, as several authors suggest, 
attended with some difficulty. 

1 Archives of Dermatology, vol. ii. No. 2, 1867. 

2 Rich, and Lou. Med. Jour., Nov. 1G. 1877. 

8 II Morgagni, May, 1881. « Le Progres Med., Oct. 29, 1881, p. 837. 



LUPUS ERYTHEMATOSUS. 263 

Partial symptomatic atrophy of the skin, in its simplest form, 
results from the traumatic action of tumors (ovarian, uterine, 
mesenteric, etc.), by which it is distended. The well-known 
results of a first pregnancy conducted to full term, are linear 
atrophies, at first of a violet tint, and later of a dead whitish hue, 
which are indistinguishable from the idiopathic lesions of simi- 
lar aspect, both clinically and pathologically. Partial symp- 
tomatic atrophy, with degeneration of the cutaneous elements 
(fatty, lardaceous, waxy, etc.), is the sequel common to a long 
list of cutaneous affections. 



5. Neoplastic. 

Lupus Erythematosus. 

Deriv. Lat. lupus, a wolf. 
Lupus erythematosus is a cutaneous new growth, displayed to the view in 
well-defined, slightl}' raised, discoid patches, often with a depressed or 
atrophied centre, colored in various shades of hypersemia, covered with 
adherent, yellowish-gray scales, and terminating, after a favorable involu- 
tion, by the production of a persistent scar. 

Symptomatology. — The disease is first exhibited in one or sev- 
eral rape-seed to bean-sized, reddish macular, slightly elevated 
from the surface, and covered with a peculiar glistening epi- 
dermis, or with an adherent scale. 

When but a single patch is formed, the primary lesion de- 
scribed above enlarges its periphery, in the course of months or 
years, by a slowly continuous development. Its reddish outer 
rim is then distinctly elevated, while its centre is depressed, 
showing either adherent, yellowish-gray scales, or a glistening 
appearance of the unbroken epidermis. It ma}^ thus attain the 
size of a small coin or a large saucer, and occur in this form 
symmetrically or asymmetrically about the cheeks, nose, eye- 
lids, forehead, ears, scalp, mouth, hands, and feet. The disks 
or patches are very well defined in outline, and of a color vary- 
ing with the complexion of the patient, from a rosy-pinkish to 
a deep purplish hue. The shape is usuallj' circular, ovalish, or 
in figures representing combinations of these. The scales, too, 
vary in color, being at times of a clear white or whitish-yellow, 
and again, often from concurrence of comedones, of a leaden or 
brownish tint. The latter are usually scanty and adherent, but 
are also, rarely, abundant. They can be occasionally seen firmly 
fastened to the orifice of the excretory duct of a sebaceous gland. 
When such a patch spreads symmetrically over the brow and 
cheeks, its figure has been likened by Hebra to the open wings 
of a butterfly. The disease is never accompanied by the occur- 
rence of other cutaneous lesions; nor is it ever displayed in 
symptoms of moisture and discharge. 



264 DISEASES OF THE SKIN'. 

When the maculae originate ns multiple lesions, the evolution 
of the disease may be accomplished by increase in the number 

of the farmer, rather than, as just described, by the peripheral 
extension of a single patch. The disease is then apt to be mani- 
fested, not only in the regions named above, but over the trunk 
and extremities, where it is likely to assume atypical forms, and 
be complicated by accesses of a febrile or neuralgic character, 
and by various cutaneous accidents, such as erysipelas, derma- 
titis, etc. 

The disease is remarkably chronic in its course, lasting in 
cases tor a quarter of a century, and throughout not interfering 
with the general health. So-called "galloping" cases are de- 
scribed by French writers, where visceral complications were the 
causes of a fatal result. The disease varies in the subjective 
sensations it produces; being at times accompanied by excessive 
itching, and often by no discomfort. It is much more common 
in women than in men, and is a disease of adult years. Kaposi 
reports a single case in one child three years of age. 

The scars left by the affection are indelible and characteristic. 
They are generally uniform and superficial; can be readily 
pinched up between the thumb and finger; are of a dull, 
whitish tint, and rendered punctate in a peculiar manner, sug- 
gesting the action of the engraver's tool in what is known as 
the "stippling" process. They are never pigmented, puckered, 
radiate, stellate, corded, or deeply attached. 

Etiology. — The causes of lupus erythematosus are unknown. 
Much has been said and written to prove that the disease is of 
scrofulous origin, but inasmuch as an immense number of scrofu- 
lous patients in all parts of the world never exhibit traces of 
the disease, it is needless to say that the proof has not been 
obtained. In by far the larger number of patients actually dis- 
playing characteristic disks of erythematous lupus, the usual 
concomitants of scrofuloderma (which see) are actually wanting. 
In many patients the most careful investigation fails to discover 
any other evidence of ill health. Yet inasmuch as many young 
women, after the puberal epoch, sutler from the chlorosis, 
anaemia, and menstrual irregularities, common to their sex and 
age, these conditions may concur. As for tuberculosis, aden- 
opathy, and malnutrition, no case of erythematous lupus yet 
presented at my clinic has chanced to occur in subjects affected 
with such symptoms. Considering the remarkable rarity of the 
disease, and the no less significant frequency of seborrhcea, the 
wonder is, not that they should occasionally concur or be trans- 
formed, the latter into the former, but that such phenomena are 
not more conspicuously and frequently noted. 

Pathology. — The disease process originates either in the peri- 
glandular tissues of the sebaceous or sudoriparous follicles and 
their ducts, or in some part of the pannieulus adiposus; in 
other words, from any point in the superficial or deep strata of 



LUPUS ERYTHEMATOSUS. 265 

the cutaneous or subcutaneous structure. Under the microscope 
the elements of both the epithelia lining the glands and of the 
connective tissue without, are seen to be multiplied and largely 
commingled with the ordinary products of an inflammatory 
process. 

Thin 1 found enormous distension of the capillaries in the 
papillae, their loops of venules being choked with red blood disks, 
and in this state almost completely occupying the digitation. 
The same was observed in the perifollicular plexuses, while yet 
the rete and glands were quite unaffected. Such alterations 
would, without question, ultimately follow as the result of the 
vascular trouble ; but the observations are of interest as lending 
color to the supposition that the primary changes in lupus ery- 
thematosus are chiefly vascular. Similar vascular dilatations, 
papillary and perifollicular, have been noted by Kaposi and 
others as concurrent with structural alterations in other por- 
tions and appendages of the skin. 

In consequence of the new growth thus formed, there is mode- 
rate elevation of the initial macule of the eruption, and a thick- 
ened rim to its centrifugally developing patches. Central re- 
sorption or atrophy of the same material in the epidermis and 
corium of such a patch, explains the wasting and depression so 
frequently observed in each. By the destruction of the glandu- 
lar and connective tissue elements in the course of a retrograde 
metamorphosis, a loss is produced which is made good by the 
peculiarly punctate form of the cicatrix which results. 

Diagnosis. — The facies of the patient, with lupus erythema- 
tosus of that region, is usually so characteristic that the disease 
is there recognized with ease. When the hand and other por- 
tions of the body are involved, the diagnosis is somewhat less 
readily established. In the former situation, the disease has a 
predilection for the dorsum, and invades the palm usually only 
by extension to it from behind. 

From lupus vulgaris it may be recognized: by its occurrence 
originally at a later period of life; by its greater tendency to 
symmetry; and by the absence of nodules, ulceration, and ex- 
tension to the deeper portions of the skin, or underlying struc- 
tures. 

In eczema there is usually some history of moisture; in ery- 
thematous lupus, never. In eczema, also, the itching is a more 
persistent and distressing symptom ; but the acuteness of even 
chronic eczema, as compared with lupus erythematosus, will suf- 
fice to distinguish the two diseases. Psoriasis is rarely, if ever, 
limited to a single patch on the face; it is also characterized by 
more lustrous and more readily exfoliating scales. Its patches 
are, furthermore, uniformly well covered with scales, and of 
equal flatness in all parts, while those of lupus erythematosus 

1 Medico-Chirurg. Trans., 1875. 



266 DISEASES OF THE SKIN". 

are irregularly squamous, the scales being often clustered at the 
orifices of the ducts of the Bebaceous glands, while the rim of 
the patch is elevated and the centre depressed. 

Treatment. — The local treatment of the patches of disease is 
nt importance. Inasmuch as tlie affection is one whose invo- 
lution is occasionally accomplished under the influence of mild 
topical applications, and is succeeded very rarely by grave 
sequelsB, it is evident that the simpler measures should be first 
adopted. Of these, green soap, applied as a plaster, or in the 
form of the Bpiritus Baponis viridis, is most serviceable. It not 
only cleanses the patch of its scales, but stimulates the surface, 
often to the extent of inducing a reparative process. The patch 
may be briskly rubbed, either with the soap or the spirit, in 
combination with hot water, after which an ointment may be 
applied, preferably Bulphur, in the strength of two drachms(8.)to 
the ounce (32.) of petroleum ointment. When a decided effect is 
produced the spirit may be discontinued, and the hot water and 
unguent for a time employed alone. A decided and beneficial 
effect can be noticed at times after the topical application of 
very hot water alone, sopped on the part for twenty minutes at 
a time with a small sponge mounted on a handle. 

Other substances for local application are : the tars; iodized. 
phenol; iodized glycerine; the iodide of sulphur; iodide of 
potassium ; iodine in fine powder and tincture ; chrysarobin 
and pyrogallic acid. The two last named have a decidedly 
favorable effect, subject, however, to the inconvenience of stain- 
ing the skin, a prominent objection in the majority of cases 
where the disease is displayed upon the face. Upon the hands 
I have employed chrysarobin with the effect of producing a 
typical cicatrix in the course of a month when the disease had 
lasted for two years. 

In exceedingly obstinate cases, those especially where the ele- 
vated rim of the erythematous disk refuses to yield to the simple 
measures described, a solution of caustic potassa in distilled 
water, one part to two or four, may be gently applied with a 
eamel'8-hair brush, and the alkali immediately neutralized by the 
addition of dilute muriatic or acetic acid, as soon as the desired 
effect is produced. That effect, it must be remembered, is super- 
ficial cauterization only. When the serosanguineous exuda- 
tion and reactive effects disappear, the rim is seen to be flattened 
and to have lost in part its violaceous blush. After such severe 
application, which should never be trusted to the hand of one 
unskilled in its use, an anodyne cerate should be spread over the 
part, containing morphia or opium. 

Vesication with cantharides, recommended by Anderson, has 
been endorsed as valuable by several authors. The same may 
be said of the mercurial plaster, of which Kaposi speaks highly; 
while he and others agree that carbolic, salicylic, nitric, chromic, 
and sulphuric acids, the chloride of zinc, the other mercurial 
preparations, and arsenical pastes, are of less value. 



LUPUS VULGARIS. 267 

Erasion by the dermal curette, in accordance with the method 
pr^aeed by Dubini, of Milan, and popularized by Volkmann, 
of Halle, has been successfully practised by many operators ; as 
also the treatment by multiple punctures. None of these have 
met with the favor in lupus erythematosus, which has been 
accorded them in lupus vulgaris; while multiple incisions by 
the lancet, or the instrument devised by Mr. Balmanno Squire 1 
have been rewarded with greater success. The instrument of 
the latter makes sixteen simultaneous and superficial incisions 
in the patch previously frozen by the ether spray. Vidal 2 lays 
stress upon attacking in this way the peripheral zone of the 
lesions. 

The internal treatment of the affection is much less satisfactory. 
Often none is indicated or required. Anderson 3 highly recom- 
mends the trituration of twenty-four grains (1.6) of iodine with a 
little water, and adding to this one ounce (32.) of starch till a uni- 
form deep blue, almost black, color is obtained, after which the 
iodide is dried by gentle heat. A large teaspoonful is given in 
a little gruel three times daily. The administration of the iodide 
of potassium and iodoform has also been followed by remarkable 
results. In general, however, cod-liver oil and the chulybeates 
will be found most serviceable, in connection with such hygienic 
regimen and diet, as is in each case specially indicated. 

Prognosis. — A favorable opinion with respect to the future of 
the disease can never be safely given; though, as regards the 
general health and comfort of the patient, there can rarely be 
question. At the same time the affection is capricious in its 
course, and may on occasions, after long periods of obstinate 
persistence, very rapidly improve under the simplest treatment. 
It is liable to relapse though not to frequent recurrence. 

Lupus Vulgaris. 

Deriv. Lat. lupus, a wolf. 
Lupus vulgaris is a neoplastic growth iu the skin or contiguous raucous mem- 
branes, manifested in the production of slowly developing, reddish-brown 
nodules, whose involution, in certain cases, is succeeded by ulceration and 
the production of a cicatrix. 

Symptomatology. — The disease is characterized at its outset 
nnd throughout its career, by the development of numerous, 
isolated, sub-epidermic nodules, varying in size from a millet- 
seed to a hemp seed, encompassed by the derma, and betrayed 
to view in the epidermis by punctiform maculations of a reddish- 
brown color, which fade under pressure with the finger. 

It is the subsequent evolution of these elements in each lupous 
eruption, often indeed somewhat difficult to appreciate, which 

1 British Medical Journal. May, 1880. 

2 Le Praticien, Nov. 14, 1881. 

3 British Medical Journal, May 1, 1880. 



268 DISEASES OF THE SKIN. 

furnishes each variety of the disease. Tims they may be dis- 
seminated irregularly as in segments of circles (lupus dissemi- 
natus, lupus 8BRPIGIN08U8); or develop in bulk to the size of 
papules or tubercles (lupus tuberculosus); or proceed to involu- 
tion by atrophy and desquamation (lupus exfoliativus); or by 
ulceration (lupus vorax, lupus exedens); or be the seat of pro- 
liferating vegetation (lupus vegetans, lupus hypertrophic 
or of corneous and papillomatue growths (lupus verrucosus). 
A number of other names are employed to designate unessential 
features of the disease, according as its lesions appear in lines, 
with well-defined margins, or display elephantiasic, acute, 
chronic, and other phenomena. 

The disease is quite rare in this country, and when seen is 
usually in papular or tubercular phases. The lesions are then 
commonly agglomerated in patches; and vary in consistency, 
size, and depth of involvement of the derma and subcutaneous 
tissues, though often distinctly circumscribed in outline. If 
resorption occur the papulo-tubercles flatten by atrophy, and 
the shining, tense, and imperfectly formed epidermis by which 
they were covered, exfoliates, leaving a cicatrix beneath. 

When ulceration of the patch occurs, a suppurative and often 
painful inflammation precedes; the ulcer, if the secretion it fur- 
nishes be permitted to dry upon its surface, very slowly spread- 
ing beneath the crust. The lupous ulcer has a dirty, purplish- 
red, indolently granulating and hemorrhagic floor, a generally 
circular outline, soft neither elevated nor undermined edges, and 
a discharge which is sufficiently abundant to drip freely from 
an exposed surface, or to dry in peculiar, broad, flat, rather uni- 
formly homogeneous crusts. 

The nose is the most frequent seat of lupus, and this organ it 
may reduce eventually to a mere atrophied miniature of its 
former shape, or utterly destroy by extensive ulcerative invasion 
of its integument, mucous membranes, and cartilages. It occurs 
also upon the cheek, chin, ears, lips, lids, scalp, neck, genitals, 
buttocks, and extremities. At times, two or more distant regions 
are affected. I have at present under my charge a young Eng- 
lishman with a palm-sized lupous patch upon and beneath the 
chin, and a large platter-sized exulceration on the right buttock 
and thigh, both of which have tormented him from his earliest 
childhood. 

The ravages of the disease are at times frightful in severity; 
not merely in consequence of the destructive ulceration to which 
it tends, but from the deformity left by its ungainly attempts at 
repair. The entire head may be thus converted into a hideous 
travesty of humanity, while yet its possessor is left with all his 
vital organs and tunctions apparently unimpaired. 

Etiology. — The causes of lupus vulgaris are absolutely unknown. 
It is certainly in no way associated with either acquired or 
hereditary syphilis. From scrofula it is as widely separated in 



LUPUS VULGARIS. 



269 



its clinical features as is lupus erythematosus; and upon this 
point the statements made above in considering the etiology of 
the last-named disease are here equally pertinent. It is neither 
contagious nor transmissible by heredity; nor is it limited to 
either sex, nor to inviduals of any social grade. It occurs at 
times in the anaemic and the asthenic; but also in those otherwise 
possessing all the symptoms of fair health and even excellent 
vigor. It is much rarer in this country than abroad, occurring 
here with nearly the frequency of lupus erythematosus. It is 



Fie;. 30. 




Section of a lupous nodule. 



d d 

b, normal corium; a, reticulum with lupous eleme 
c, d, giant cells. (After Kaposi.) 



generally first seen between the third and sixth years of life; 
after the thirtieth year of life practically never, unless there have 
been prior symptoms of the disease. 

Pathology. — For a knowledge of the microscopic characters of 
lupus vulgaris we are largely indebted to the Germans, whose 
opportunities for the study of the disease are unequalled. Vir- 
chow, Auspitz, Billroth, Lang, Kaposi, Klebs, and Stilling, with 
Thin, of England, have amply contributed to the subject; and 
the result of their investigations may be concisely stated as fol- 
lows: — 



270 DISEASES OF THE SKIN. 

The more recent nodules when divided exhibit at different 
depl hs of i he corinra roundish masses, comparable to a nidus or 
nest, above which spreads an unaltered epidermis. These foci 
of the disease are well defined in outline, and of a reddish-yel- 
lowisb tint. Around them is woven a network of connective 
tissue bundles; with larger and smaller interspaces containing 
vascular elements, and also so-called cells and nuclei, proba- 
bly masses of protoplasm originating in the reversion of the 
connective tissue elements to the embryonal state. Retro- 
gression is marked by a diminished vascularity; while the ele- 
ments disappear by resorption, or by the destructive process of 
ulceration followed by the cicatrix. Both Kaposi and Lang 
agree that the vascular and fibrous elements of the lupous mass 
are capable of developing new connective tissue which later un- 
dergoes retraction. This is curiously in accord with the clinical 
result of Squires' treatment by multiple linear scarification, in 
which the lupous growth, after replacing the normal elements 
of the derma, becomes itself the source of the new material of 
repair. 

When the disease is extending, the lupous growth, spreading 
along the vascular elements of the derma, involves finally the 
rete and the panniculus adiposus. The nest-like agglomerations 
disappear; there is in their stead an irregularly diffuse infiltra- 
tion, producing subsequently hypertrophic, atrophic, desquama- 
tive, suppurative, or ulcerative sequelae. Finally, the glands of 
the skin may become involved, the hairs falling from their fol- 
licles, the sebaceous glands either becoming obliterated, or leav- 
ing their acini stuffed with epidermal masses which distend them 
in milium-like bodies grouped about a cicatricial pedicle. When, 
as observed by several authors, there is coincidence of lupus vul- 
garis and epithelioma, the latter is developed from epithelial 
cones, described by Kaposi as penetrating downward and in 
other directions from the sweat glands and the root-sheaths of 
the hairs. 

Diagnosis. — Epithelioma, though rarely resembling lupus vul- 
garis, is more often designated by that than by any other false 
title. Great confusion lias arisen from the looseness with which 
several surgical authors have furnished illustrations of "lupus 
exedens," which were really pictures of cancer. JJut the latter 
is rarely a disease of early life, and when of such early occur- 
rence never persists to adult years; while lupus is such exactly 
in the vast majority of all cases. The nodules of lupus are 
absent in epithelioma; and the evolution of the disease slower, 
less painful, and, in its earlier periods certainly, of deeper situ- 
ation. The ulcer of epithelioma is more often defined and 
single; its edges, indurated and everted; its floor, uneven and 
glazed; its secretion, scanty and occasionally fetid; its base, a 
mass of indurated tissue. Lupous ulcers are often illy-defined 
and multiple; their edges, soft and inconspicuous, neither everted 



LUPUS VULGARIS. 271 

nor undermined; their floors, granulating and flattened; their 
secretion, relatively profuse and generally odorless; their bases, 
soft and pliable though occasionally indurated. 

Tubercular, serpiginous, and ulcerative lesions of syphilis may 
at times resemble certain forms of lupus. In any doubtful case 
a history of infection, of other types of cutaneous disease, of 
mucous patches, of adenopathy, of abortions in the female, etc., 
should aid in the recognition of syphilis. The suspected lesions 
should be carefully examined for the purpose of distinguishing 
characteristic lupous nodules in the patch itself, or the periphery 
of any exfoliating area. In the case of an adult, a long history 
of lupus can be often obtained; and it is worthy of note that 
syphilis with exceeding rarity displays for long periods of time 
a single exanthematous lesion or aggregation of such lesions in 
one part of the body exclusively. The lupous ulcers, often mul- 
tiple and isolated, insensitive, rarely of well determined outline, 
never reniform or horse-shoe shaped, with supple edges and 
granulating Moor, covered with crusts like soiled parchment of 
uniform thickness, do not resemble those of syphilis. The latter 
are often painful, single, circular, and clean cut in contour, with 
offensive greenish and blackish crusts resembling oyster shells. 
The cicatrices of syphilis are elegant, smooth, delicate, super- 
ficial, circular, and, after pigmentation has disappeared, dead- 
white in color. Those of lupus are irregular, indurated, deform- 
ing, yellowish-white, and reddish-yellow. 

Lupus erythematosus is even more readily distinguished by 
its characteristics; including the absence of nodules, ulcers, and 
crusts, and the superficial character of the disease process, the 
scaliness, and occasional symmetry of the patch. Cases are de- 
scribed of intermediate forms between lupus erythematosus and 
lupus vulgaris, but I have never been able to persuade myself 
that these really occur. The two diseases, unfortunately some- 
what similar in name, are unquestionably distinct in character. 
The so-called intermediate forms shown to me have been in every 
instance cases of flat and. scaling epitheliomatous infiltrations 
going on to ulceration. 

Treatment. — Without question the local treatment of lupus 
vulgaris by a modification of the Dubini-Volktnann method 
(that namely by multiple linear scarification) deserves first men- 
tion; as it is claimed with some justice to have changed the 
prognosis of the disease. It is somewhat doubtful whether any- 
thing is to be gained by either a preliminary freezing of the 
part, or the use of the cutting instrument of many blades devised 
by Squire, of which mention is made in the preceding article. 
The incisions are best produced with a delicate bistoury held in 
the fingers like a pen. They should be in parallel lines, closely 
set together, and crossed; should extend completely through the 
depth of the lupous growth ; and this is determinable after some 
practice by the cessation of the creaking resistance which the 



272 DISEASES OF THE SKIN. 

blade fails to discover in normal tissue. Further, they should 
extend laterally beyond the borders of the lupous patch into the 
Bound peripheral zone. The bleeding is trifling and readily 
arrested by firmly pressing small pieces of fine sponge, lint, or 
absorbent cotton over the part. The edges of the incision unite 
either by granulation or first intention; and in both cases seem 
to serve as starting points of the reparative process, the material 
for which, as already pointed out, seems to be supplied from the 
lupous nests themselves. Subsequent operations, when needed, 
require a previous freezing of the affected surface. 

Less efficacious, more painful, and much move disfiguring in 
its results, is the method of erasion by thedermal curetTte. This 
instrument is a sharp-edged spoon with a fenestrum in the howl 
to permit escape of the debris. With it, the frozen lupous 
growth may be completely scraped away, and, if necessary, caus- 
tics subsequently applied. The method of treatment by multi- 
ple punctures instead of incisions, is efficacious, though less 
satisfactory. Schilt', 1 and Auspitz, have combined puncture with 
the introduction of iodized glycerine (one part of the former to 
twenty of the latter), the first named operator using a tubular 
needle filled from a rubber pipette. 

I have on several occasions, both in public and private, em- 
ployed the Paquelin knife without anaesthesia and with good 
results. The finer blades, especially manufactured for the pur- 
pose, are thrust at a red heat again and again through the lu- 
pous tissue until it is destroyed in its depth. Over the whole, 
the lower blade is firmly passed and pressed, the blackish coal 
resulting being the best subsequent dressing after the serous ex- 
udation ceases. Americans are generally credited, abroad, with 
a preference for erasion followed by tne galvano- or thermo- 
cautery. 

Inferior, I believe, to all these methods, is the now somewhat 
obsolete treatment by chemical cauterization alone. The various 
acids and alkalies, nitrate of silver, arsenical, mercurial, and zinc 
compounds, have all been thus employed, and each, in suitably 
selected cases, may be productive of fairly satisfactory results. 

For the cases which do not require surgical or other operative 
interference, simple local applications may be made, such as oil}' 
and fatty substances for the softening of crusts; stimulating 
dressings of tar, iodated glycerine, carbolized glycerine, iodized 
phenol, napbthol, chrysarobin, pyrogallic acid and iodoform ; as 
also the carbolated unguents appropriate for the reparative phases 
of the ulcer left after the destruction of the lupous growth. 

The internal treatment of lupus vulgaris is practically that 
indicated by the condition of the patient ; inasmuch as no medi- 
cament is known to be capable, alter ingestion, of relieving the 
victim of his local ailment. Of the articles in this category 

' Viertel. f. Derm. u. Syph , Nos. 2 and 3, 1880. 



KELOID. 



273 



none will be more often indicated than cod-liver oil, the chaly- 
beates, the bitters, the preparations of iodine, and possibly phos- 
phorus. Arsenic and mercury are powerless to prevent the 
extension of the disease. With these, it is needless to add, a 
diet of the most generous character is to be supplied, and the 
rules of hygiene enforced. 

Keloid. 

Deriv. Gr. ^i*?. a claw. 
Keloid is a benign cutaneous neoplasm, occurring as one or more elevated, 
whitish and reddish, firm and elastic nodules, plaques, ridges, radiating strife, 
or as several of such forms in combination, resembling an hypertrophied 
cicatrix. 

Symptomatology. — The' term Keloid, first given to this disease 
by Alibert, should be restricted to it exclusively. The symp- 
toms are, dense, generally elastic, nodules embedded in the corium 

Fig. 31. 




Keloid growths. 



and firmly attached to it. They are generally very slow of evo- 
lution, and, having ouce attained their full development and 
assumed one of the several shapes which they affect, usually per- 
sist for a lifetime. These forms are globular or semi-globular 
18 



274 diseases or THE skin. 

nodules, buttons, or plaques, with roundish or ovoid outline; 
linear elevated striae, bands, ridges resembling cords, ribbons, or 
tapes, in irregular outline and disposition; or combinations of 
two or more of these figures. A common form over the sternum, 
and in other situations where the development of the growth in 
every direction is unimpeded, i9 that of a larger central mass 
with two or more diminishing and declining prolongations 
hearing a remote resemblance to the body and claws of a crab. 
The lesions vary in size from a small pea to a large saucer, the 
largest including the outlying points of the limbs or radiating 
ridges. Over it the skin is reddish or whitish in color, smooth, 
hairless, and occasionally hyper-sensitive to pressure and heat. 
The growth is also at times the seat of spontaneous pain. 

The most frequent site of the disease is the anterior surface 
of the chest, but it is observed also upon the face, neck, ears, 
breast, hands, between the scapula?, and on the extremities. It 
may be encountered indeed upon any portion of the body. I 
have seen it upon the penis of the negro. 

A case of scar-keloid undergoing involution, has been described 
by Dyce Duckworth, in a man, aged fifty, who sutfered from 
rheumatic fever, on two occasions, ten years before the date of 
report. He had pericarditis, and was blistered over the prsecor- 
dia. Nine months afterward, lines of keloid growth began to 
form in the scar left by the blister, and they extended rapidly. 
In two years' time they were still enlarging. In seven years, 
some subsidence was noticed, and, when exhibited ten years 
after their first formation, involution was markedly progressing. 
The case illustrates the frequent, origin of keloid in scar tissue, 
its common occurrence over the sternum, and the fact of the 
subsidence of the new growth in the course of time. 1 

Etiology. — The disease occurs both spontaneously and as an 
hypertrophic development from a simple scar, in persons of all 
ages and sexes, but with a decided preference for the negro race. 
It is often the result of traumatism, as from piercing the ears 
for ear-rings, the operations of surgery, leech-bites, the deeper 
burns from lire, and wounds inflicted by accident. I have seen 
it in several instances follow cutting the hands with glass; and 
once, in the same situation, from the wound inflicted by the spur 
of a cock. It is sufficiently common after the occurrence of aene 
indurata, but the latter is of all its forms the least persistent. 
In general it may be concluded, however, that it occurs chiefly 
in those whose skins have a special tendency to such develop- 
ment. 

Pathology. — Kaposi has demonstrated a. difference, rather of 
disposition than of kind, between keloid, hypertrophied cica- 
trix, and cicatricial keloid. In the first, the epidermis is intact, 
while the corium at one level exhibits whitish, thickened, and 

) Brit. Med. Jour., October 8, 1881, p. 597. 



KELOID. 275 

closely packed bundles of fibrous elements, lying parallel to tbe 
long axis of the tumor and the surface of the skin, traversed 
here and there diagonally by similar bundles, all probably de- 
rived originally from the sheaths of the bloodvessels. In the 
second, the papillary layer of the corium has been destroyed by 
the process of which the cicatrix is a resultant, and the latter 
does not surpass its original limits by invading the unaltered 
peripheral tissues. The connective-tissue bundles are here also 
much less closely aggregated. In the third, the two forms de- 
scribed above can be seen combined, the papillary layer being- 
destroyed, and the peripheral parts invaded by the connective- 
tissue new growth. 

Diagnosis. — The features of keloid are readily recognized by 
its peculiarities described above. It can only be confounded 
with cicatrix; and in any doubtful case a distinction between 
hypertrophied cicatrix and keloid would be needless from any 
point of view. Keloid following the piercing of the lobule of 
the ear for the insertion of ear-rings, is distinguishable by pinch- 
ing the part between the fingers, when a globular, pea to cherry- 
sized mass will be felt firmly imbedded in the derma between 
the reflected folds of the integument. Upon the face, after the 
occurrence of acne, it can be usually seen as a puckered ridge, 
often transverse in direction, occupying the region of the cheek. 
Treatment. — Removal of keloid by cauterization and excision 
is not to be practised, as the growth does not fail to reappear. 
Vidal 1 has successfully employed multiple linear scarifications. 
Various stimulating applications may also be made with a view 
to promote resorption, such as the spirit of green soap, iodated 
glycerine, iodine in ointment and tincture, mercurial and lead 
plasters. Where there is pain, anodyne unguents may be em- 
ployed topically, such as the freshly prepared belladonna plaster, 
or the ointments of belladonna, stramonium, and opium. By 
far the most elegant of these, and one which also is capable of 
producing an alterative effect, is the oleate of mercury and mor- 
phia, manufactured by Squibb, of Brooklyn. 

Internally, quinine, strychnine, arsenic, and the iodide of 
potassium have been exhibited with varying success. I have 
never happened to see a case where internal medication had 
been followed by appreciable results in the diminution of the 
growth. 

Prognosis. — As regards the general condition of the patient 
the prognosis is favorable. Very rarely there is spontaneous 
resorption of the nodule or tumor. Generally the latter may 
be expected to persist, after full evolution is attained, for an 
indefinite period of time. Keloid of the cheeks following acne 
is usually smoothed down in the process of time, after the dis- 
appearance of the sebaceous gland disorder, till the deformity 
is greatly lessened, and often scarcely noticeable. 

Gaz. Des. Ilopit., January 29, 1881, p. 94. 



276 



DISEASES OF THE SKIN". 



Der 



Molluscum Fibrosum. 

Lat. molluseua, soft; and libra, a fibre. 



Molluscous fibromata are cutaneous or subcutaneous neoplastic tumors, pro- 
jecting in different degrees from the surface, single or multiple, of several 
grades of density, distinctly circumscribed, covered either by a sound and 
attached, or rarely by an ulcerated integument, and varying in size from a 
small pea to a foetal bead. 

Symptomatology. — Molluscum fibrosum is a disease character- 
ize. I usually by the occurrence of numerous roundish, sottish, 
semi-solid, or Bolid growths, varying in size from that of a small 
]>ea to tumors of several pounds weight, though more rarely the 
neoplasm is single. They are situated, when quite small, within 




Molluscum Hbrosam. (Gross ) 



siugle fibroma. (From a photograph.) 



MOLLUSCUM FIBROSUM. 277 

or beneath the skin, where they can be distinguished as dis- 
tinctly circumscribed nodules, buttons, or plaques often slightly 
projecting. When more fully developed they become sessile, 
pedunculated, or largely pendulous tumors, hanging from the 
part to which they are attached so as to resemble in shape a 
cherry, a nipple, a pear, or a sausage. They are commonly cov- 
ered by an iutegumeut which is natural in color and suppleness, 
though the latter may be traversed by bloodvessels ; sprinkled 
with comedones or patent orifices of sebaceous gland-ducts, 
thinned or thickened, or in a. state of ulceration ; the last named 
being usually the result of externally operating causes in tumors 
of large size. They are productive of no subjective sensation 
beyond the more or less uncomfortable tension produced by the 
weight of those attaining a great development. When mul- 
tiple, they may be seen in various degrees of development, cov- 
ering in hundreds the entire body, especially the scalp, face, 
trunk, genitals, and extremities. Upon the lids, they may inter- 
fere with vision by the production of ptosis. To the touch they 
may be felt as softish, somewhat elastic, firm, or lobulated 
masses, though at times nothing but a double fold of skin can 
be perceived, or a cordlike contained body. 

Etiology. — The disease is peculiar to neither sex ; and, though 
observed in adults, is commonly first developed in childhood. 
It cannot be claimed as peculiar to any race, though in this 
country the negroes have probably furnished the largest field 
for its observation. Hebra called attention to the low standard 
of physical and mental development of the subjects of the dis- 
ease seen by him, a fact well illustrated in a case presented at 
my clinic during the past winter, the patient being an exceed- 
ingly myopic, poorly nourished, white, male dwarf, whose body 
was literally covered with fibromata from the scalp to the feet. 
In view of this well-established clinical fact, the hereditability 
of the disease, which is rendered probable by recorded observa- 
tions, seems capable of explanation. It has been noted in three 
successive generations and in several children of one family. 
The precise cause of the disease is unknown. It is, however, 
reasonable to conclude that it is due to a vice of local develop- 
ment under the influence of a constitutional predisposition. 

Pathology. — Fibromata originate in gelatinous connective-tis- 
sue elements, which undergo metamorphosis into bundles of 
fibres, the tumors always exhibiting more of the formed mate- 
rial in the outer, and the formative or protoplasmic material in 
the central parts of the mass. The fibrous bundles pass down- 
ward, and unite with those of the derma or subcutaneous tissue, 
forming thus a firm attachment for the pedicle of all peduncu- 
lated tumors. There is some question as to whether these 
growths originate in the deep interspaces of the corium, or in 
the connective tissue about the hair follicles or fat lobules. 



278 DISEASES OF THE SKIN. 

Heitzmann 1 divides the fibrous tumors of the skin into two 
classes: "a. I 'ciisc. fibrous, connective-tissue bundles with rela- 
tively few spindle shaped protoplasmic bodies or solid nuclei 
running in all directions, apparently without any regularity, 
thus producing a hard and dense felt-like tissue. This is an 
imitation of the structure of aponeuroses or inter-articular liga- 
ments, if scantily supplied with bloodvessels; or of periosteum 
and perichondrium, if holding a larger number of bloodvessels. 
6. Dense, ■fibrous, connective- tissue bundles, holding in their 
meshes a jelly-like hasis substance, with a small number of pro- 
toplasmic bodies. This variety is an imitation of the structure 
met with in the valves of the heart mainly upon their insertions. 
The supply of bloodvessels, as a rule, is scanty. Both varieties 
are common tumors of the skin, in the shape of hard, sessile 
nodules and nodes (hard fibroma); or tumors of greatly varying 
size, but softer consistence (soft or myxo-fibroma); or shallow, 
as a rule pigmented, elevations of the skin (nsevi); or scar-like, 
irregularly branching, sometimes freely vascularized new forma- 
tions (keloid)." 

Diagnosis. — The tumors of molluseum tibrosum are to be dis- 
tinguished clinically from multiple cutaneous sarcomata, by the 
violaceous or reddish color of the latter, the absence of peduncu- 
lation, their greater tendency to ulceration, and their evidently 
malignant character. From the tubercles of lepra, they are dif- 
ferentiated by the entire absence of constitutional impairment 
and their general development in far greater multiplicity. The 
tumors of molluseum epitheliale differ in their contents, super- 
ficial location, and in the frequent presence of the dark punctum 
at their summits. 

Neuroma is usually painful; lipoma less frequently multiple 
and pedunculated, and more suggestive, when handled, of the 
"pillowy" sensation to the touch. Warty growths are readily 
distinguished by their vegetating summits; and the gummata 
of syphilis, by the concomitant or prior symptoms of the exist- 
ence of lues. 

Treatment. — The treatment of large single fibromata is surgi- 
cal; involving the employment of knife, ligature, ecraseur, or 
galvano- or thermocauterization. Multiple lesions are often so 
numerous as to forbid such interference. When there is a dis- 
tinct vice or development of inherited tendency to the disease, 
little can be accomplished in the way of treatment. 

Prognosis. — Rarely, one or more of these lesions disappear by 
spontaneous involution. More commonly they persist after their 
evolution is completed. Marasmus, tuherculosis, and a fatal re- 
sult may occur. One or several of the tumors may become 
sources of danger from the occurrence in them of an active in- 
flammation with resulting degeneration and septicemic conse- 

1 Archives of Derm., Oct. 1880, p. 378. 



XANTHOMA. 279 

quences. The disease, however, does not, in many cases, shorten 
life. In general, the prognosis of multiple libromata may be 
regarded as unfavorable. 

Xanthoma. 

Deriv. Gr. ^avdog, yellow. 

Xanthoma is a cutaneous neoplasm, exhibited in one or several, isolated or 
grouped, occasionally symmetrical, flat or slightly elevated, yellowish ma- 
cules, papules, plaques or tubercles, which arc most commonly situated upon 
the eyelids. 

Symptomatology. — The macular symptoms of the disease are 
bean- to finger-sized plaques, either quite fiat or with slightly 
elevated borders, often constituted by an aggregation of millet- 
seed-sized lesions, and covered with an apparently normal in- 
tegument. In color they vary from light and chrome-yellow to 
the '• coffee and milk" shade; and in shape they may be puncti- 
form, roundish, ovalish, elongated, or quite irregularly grouped. 
They are distinctly circumscribed, and when gathered between 
the thumb and finger do not produce the sensation of the pres- 
ence of a foreign material. They are most often seen upon the 
eyelids near the inner canthus, where they may be symmetri- 
cally disposed about the two orbits. But they may invade also 
the peri-orbicular region, as also, rarely, the cheeks, the nose, 
the ears, and the nucha. They are rarely productive of subjec- 
tive sensation, being occasionally the seat of slight pruritus. 
This is the commoner form of the disease, and is termed xan- 
thoma planum. 

The tubercular lesions of the same affection, known as xan- 
thoma tuberculosum, may coexist with the plane lesion de- 
scribed above, and scarcely differ from the latter save in their 
greater development. They are whitish or yellowish papules, 
plaques, and tubercles, circumscribed in contour, covered with 
an unaltered epidermis, and determinable by palpation as having 
greater consistence than the flat macules. They are less fre- 
quently seen upon the lids, but occur upon the scalp, cheeks, 
palmar and plantar surfaces, the genital regions, and about the 
joints of the digits. 

Other exaggerated forms are described. Thus sessile or pe- 
dunculated tumors, cutaneous or subcutaneous in their attach- 
ment, nut- to hen's egg in size, and originating in one or an- 
other of the lesions named above, are described by Gary 1 and 
Chambard. 2 To these the name xanthoma tuberosum should 
be limited. Xanthoma multiplex is the form in which the 
lesions, usually first manifested in the sites of election and in 
their simplest development, proceed to a gradual invasion of 

1 Ann. de Derm, et de Syph., 1880, p. 75. 

2 Archiv. de Phys. norm et path., Sept. and Dec. 1879. 



280 DISEASES OF THE SKIX. 

the trunk and extremities. Occasionally the mucous surfaces 
of the mouth, of the respiratory, and ^astro-intestinal tracts are 
involved ; as also of the surfaces of the peritoneum, endocardium, 
and larger nrteries. 

In a proportion of eases, the disease is accompanied by a 
generalized coloration of the skin in a yellowish shade, which 
has been variously interpreted as a xanthomatous dyschromia, 
and as a true icterus. The former is the more probable explana- 
tion of the fact, as in such cases the urine and viscera have been 
found normal. 

Korach 1 has described the interesting case of a twenty-five- 
year old woman suffering from chronic icterus, produced by 
closure of the ductus eholedochus. Besides the typical patches 
of xanthelasma on the lids, the skin surface was generally and 
similarly affected. Thus the extensor faces of the extremities, 
the palms of the hands, nates, and other parts, were extensively 
covered with sago-grain to pepper-corn sized papules and tuber- 
cles of xanthoma, both flat and elevated. 

Etiology. — The causes of the disease are unknown. In many 
cases the lesions are first observed in early childhood, though 
they are encountered also in middle and later life. 

Pathology. — The latest pathological studies of the affection 
have been made by Chamhard, 2 whose conclusions are briefly 
these: "The three forms, plane, tubercular, and tuberose, are 
the results of two processes, irritative and retrogressive; the 
first prevalent in the tubercular and tuberose forms, the last in 
1 be plane variety. 

" In xanthoma planum, the irritative process is represented by 
an albuminous tumefaction of the connective-tissue elements, 
with proliferation of their nuclei; the retrogressive process, by 
a fatty degeneration of their protoplasm. In the other forms, 
the irritative process is distinguished by the new formation of 
connective tissue; the retrogressive, by a fatty infiltration of 
the old and newly formed connective-tissue elements. In both 
forms, not only the connective tissue of the derma, but also the 
vascular, glandular, and nervous organs, within and about the 
sclerosed nodules, are invaded. The sclerotic process involves 
also the fibrous envelope of the sebaceous and sudoriparous 
glands (peradenitis); the internal and external sheaths of the 
vessels (peri-arteritis, endarteritis obliterans); and the lamellar 
sheath and intra-fascicular connective tissue of the nerves (peri- 
neuritis, endoneuritis). The nervous involvement is thought to 
explain not only the pain, but also the tenderness peculiar to 
the xanthelasmic tubercles." 

Diagnosis. — Milia are occasionally associated upon the lids in 
the form of oval plaques, but are distinguishable from xanthoma 
by the possibility of expressing their contents. 

1 Dfutsch. Med. Wochensch., No. 23, 1881. 2 Loc. cit. 



XANTHOMA. 281 

Treatment. — Erasion and excision are the sole recognized means 
of removing xanthoma. Care should be taken in such opera- 
tions to avoid a consequent ectropion when the operation is per- 
formed upon the skin of the eyelids. The Paquelin knife, which 
I have employed for this purpose, is objectionable, on account of 
the radiation of the heat to the globe of the eye. With the 
tumor slipped through an aperture in a thin sheet of asbestos 
paper, such as is now found in the markets, this inconvenience 
might be avoided. 

Prognosis. — The lesions, when not removed, are liable to per- 
sist through life Spontaneous involution is not known to occur. 
The French authors, who have given considerable attention to 
this subject, are disposed to believe that some cases of xanthoma 
tuberosum, with permanent xanthochromia and involvement of 
the inner coats of the larger vessels, may prove serious. 

Adenoma. 

Certain whitish or j-ellowish, pin-head sized, rounded and iso- 
lated lesions, with gelatinous contents, scattered over the face 
of persons in middle life and advanced years, are occasionally 
seen either flattened or slightly elevated above the level of the 
integument. They have been described under the title of " col- 
loid degeneration of the skin," but are probably instances of 
adenoma of small acini of the sebaceous glands, the epithelium 
of which has undergone colloid degeneration. According to 
Heitzniann, the distinguishing feature of them all is a wreath 
of cuboidal or short columnar epithelium, inclosing a distinct 
cavity. Besnier, 1 however, concludes that the connective-tissue 
elements of the derma are primarily involved in the colloid de- 
generation; and the glandular epithelia, secondarily. 

Myoma Cutis. 

Tumors of the skin composed of smooth muscular fibres are 
known as myomata. or lyomyomata. But little attention had 
been attracted to these new growths up to a recent date. Jullien, 2 
however, in a review of the latest contribution to the subject 
made by Messrs. Brigidi and Marcacci, of Florence, and pub- 
lished by them in the Imparziale, in 1881, gives a full capitula- 
tion of the bibliography of the subject. 3 

From these reported cases it appears that the tumors originate 
as usually single, though occasionally multiple, elevated, dis- 
seminated, small pin-head to orange-sized, macular or tubercular 
lesions, the skin covering which is smooth, stretched, and glis- 

1 Ann. de Derm, et de Syph., t. x., Nov. 5 and 6, 1879. 

2 Anuales de Derm, et de Syph., t. iii. 2me Ser., Fev. 25, 1882. 

3 1854, Yirchow ; 1858, Forster, Verneuil ; 1864, Klob, two observations ; 1871, 
Challand, two observations; 1873, Marcano Sokoloff; 1878, Axel-Key, Sau- 
tesson ; 1880, Besnier ; 1881, Arnozan and Vaillard ; Brigidi and Marcacci. 



282 DISEASES OF THE SKIN. 

ten ins:, with n rosy or dark reddish tint, paling or not under 
pressure. The developed lesions may l>e sessile or pedunculated, 

and cither intensely painful, pruritic or remarkably sensitive to 
cold. Under the influence of muscular contractions, there may 
he, as in the cases of Challand and Axel-Key, slow vermicular 
motion and frequent, changes of volume, or other evidences of 
contractility. They occur either as generalized lesions, or limited 
to the thorax, scrol urn, mammae, labia majora and the hands and 
feet, including the palmar and plantar surfaces. The ages of the 
patients varied from the twenty-fifth to the sixty-fifth year of 
life. Of thirteen persons whose sex was given, five were males 
and eight females. 

Pathologically, these cases were reported as either pure myo- 
mata or highly vascular types of myoma telangiectodes, and 
FIBRO-MYOMA. Verueuil's case resembled a neuroma, as it con- 
tained not only smooth and striated muscular elements and blood- 
vessels, but also nerves. The case ot' Axel-Key is recorded as 
Olie Of LYMPHANGIECTASIA FIBRO-MYOMA. 

The disease is a benign new growth, and is not to be con- 
founded with prurigo, lepra, syphilitic gumma, neuroma, mye- 
loma, and molluscuin fibrosum. 

Rhinoscleroma. 

Deriv. Gr. pi;, or p«, the nose ; and s-xXuse'c, hard. 
Rhinoscleroma is a new growth of the skin and mucous membranes of the 
nose and contiguous parts, characterized by the formation of exceedingly- 
dense, elastic, and painful, flattened or elevated, plaques, nodules, or tuber- 
cles, which may be isolated or confluent. 

Symptomatology. — A knowledge of this rare disease, first de- 
scribed by Ilebra and Kaposi in 1870, 1 has been obtained solely 
from a study of some thirty-five cases observed by these au- 
thors. The following is a concise statement of their description 
of the malady : — 

The disease commonly begins in the septum or a single ala of 
the nose without inflammatory symptoms. The involved parts 
slowly enlarge, and become finally as dense as ivory. The in- 
dividual lesions are flat patches, or elevated and circumscribed 
nodules, papules, and tubercles, painful upon pressure, movable 
to a certain extent over underlying tissues, and covered by either 
a normal integument, or a light or dark-red, shining, vascular 
epidermis. Neither hairs nor glands are discernible over the 
lesions. As the disease progresses, the ala? become enlarged, flat- 
tened, and so indurated that they cannot be pressed together, 
while respiration may be impeded by stenosis of the nares. The 
process may extend to the neighboring parts, involving thus 
the upper lip, gums, velum, epiglottis, and larynx, the teeth 

1 Wien. Med. Wocb., No. 1, 1870. 



RHINOSCLEROMA. 283 

meanwhile falling from their sockets, and the soft palate be- 
coming in some cases perforated. Involution of the process has 
not been observed, as the lesions do not degenerate by ulcera- 
tion. Max. Zeissl, 1 however, reports a single case in which there 
had been ulcerative destruction of the entire left nostril, as well 
as the tip and right ala of the nose. Occasionally superficial 
excoriations have occurred, but very rarely a diminution in 
the consistency of the mass. The disease is exceedingly chronic, 
requiring years for its development ; and though the affected 
parts are painful on pressure, they are otherwise not the seat of 
subjective sensation. 

Etiology. — The cause of the disease is entirely unknown. It 
is observed between the fifteenth and fortieth years in persons 
of all social conditions and individuals of both sexes, free from 
syphilitic, strumous, tubercular, and other cachexiee. 

Pathology. — Kaposi has observed, as anatomical lesions of the 
disease, a dense infiltration of the corium and its papillary layer, 
with small, closely packed elements, which he recognizes as a 
true new formation. He considers this as analogous to the 
small-celled sarcoma (small globo-myeloma, of Heitzmann), inas- 
much as Mikulicz, G-eber, and Billroth have seen some of the 
elements of the neoplasm transformed into osseous formations, 
transformations sufficiently common in sarcomatous tumors. 

Diagnosis. — The disease can hardly be mistaken for another 
in consequence of its situation, the disfigurement it occasions, the 
ivory-like elasticity and induration of the affected parts, and the 
rarity of ulcerative degeneration. As distinguished from syphi- 
lis, it is known to be entirely unaffected by specific medication. 
From the variety of acne rosacea of the nose, known as rhino- 
phyma, it is readily differentiated by the softness and compres- 
sibility of the latter, and its evident vascular and glandular 
composition. 

Treatment. — The method of relief thus far employed is a total 
or partial extirpation of the neoplasm. Kaposi speaks of dila- 
tation of the nares by means of laminaria and compressed 
sponge, where there is actual or threatened nasal occlusion. 
Both excision by the knife and destruction by caustics have, 
however, been found to secure merely temporary benefit, as the 
growth is reproduced with some rapidity. 

Prognosis.— The future of the patient is grave. The disease 
not only persists and recurs after operative interference, but may 
endanger life by obstruction of the nostrils. Zeissl's case 2 proved 
fatal in ten years after the disease first appeared. 

1 Wien! Med. Woch., 1880, p. 621. 2 Loc. tit. 



284 DISEASES OF THE SKIN, 



Clasb II.— of the sebaceous glands and periglandular 

TISSUES. 

1. Anomalies of Secretion. 

The disorders named in this class all depend upon functional 
derangements of the sebaceous glands, whose office, it will be 
remembered, is the supply of the physiological unguent of the 
skin. This derangement may be true of the secretion itself, or 
of the mode of its excretion. 

Seborrhoea. 

Seborrhoea is a functional disorder of the sebaceous glands, exhibited in an 
abnormal condition of tbe secretion as it collects upon the surface of the skin. 

Symptomatology. — Seborrhoea occurs in two varieties, accord- 
ing t<> the condition of the excreted product. These are known 
as seborrhoea sicca and seborrhoea oleosa. The two forms are 
recognized clinically as of separate occurrence; and also as ex- 
isting occasionally at the same time in one person. Either form 
of the disease may be limited to certain sites of preference, or 
he generalized so as to extend over all portions of the body pro- 
vided with sebaceous glands. The most common seats of the 
disease are: the scalp, the face, the genital region, the dorsum 
of the body between the scapulae, and the anterior surface of the 
chest. As a physiological state, its features are seen in the ver- 
nix caseosa of the newly born infant; and in pathological symp- 
toms, it appears in all subsequent periods of life, and in both 
sexes. As the sebaceous glands are mainly appendages of the hair 
follicles, the lesions of the disease differ somewhat, according as 
they occur in regions covered with long or lanugo hairs. In 
the same proportion, a difference exists in the career of the dis- 
ease. At times it is a trivial and short-lived affection ; at others 
it is persistent and intractable, lasting for years, and possibly 
for a lifetime. The individuals thus affected exhibit a difference 
also with respect to the general condition of their health. Some 
are anaemic, chlorotic, or asthenic; some are of the sanguine 
temperament, fleshy, red-faced, and thick-skinned ; others again 
are absolutely healthy, so far as can be discovered, except for 
the local sebaceous disorder. This last fact is one of some sig- 
nificance. I have seen exaggerated types of seborrhoea in vigorous 
men who had worn for one mouth merely, a skullcap, to which 
was fastened an apparatus for relief of fracture of the lower jaw. 

The skin affected with a seborrhoea is usually anaemic, and 
either dry or humid. In such cases the subjective sensations 



SEBORRHEA. 285 

are either slight and limited to a moderate degree of itching, of 
which the patient does not complain till he is questioned upon 
the subject, or altogether wanting. At other times the glands, 
or periglandular tissues, are affected with a mild form of inflam- 
mation, and then the involved surface may be reddened and 
become the seat of a considerable pruritus. 

Seborrhoea Sicca (or Squamosa), 

is the most common of all forms of the disease, and occurs upon 
both the hairy and non-hairy portions of the integument. In 
the former situation, where it is vulgarly known as " dandruff," 
it is called — 

Seborrhea capillitii, in consequence of its limitation to the 
hairy scalp. In its ordinary manifestations, the affection is 
recognized in the adult, by the formation in this region, of 
greasy, whitish or yellowish pellicles of dried sebaceous matter, 
which may be freely shed from the surface and cover the shoul- 
ders of the individual whose scalp is involved. At other times 
these fatty plates are more or less adherent to the scalp-surface, 
or piled up in laminae one upon another. These may closely 
mat the hairs together, perceptibly near the exit of the latter 
from their follicles; or be abundantly disseminated through 
the mass of the hairs, some of which penetrate a flattened greasy 
scale, as a twig might be passed through the centre of a leaf. In 
consequence of their deprivation of unguent, the hairs to which, 
the affected glands are accessory, become dry and lustreless, and 
fall from their follicles. If the process he not arrested, atrophy 
of the hair follicle ensues, and the resulting alopecia is perma- 
nent. 

Fortunately, the seborrhoea is usually symmetrical, and, cor- 
respondingly, the baldness which it occasions. The disfigure- 
ment then resulting is of the character of symmetrical senile 
alopecia, and is chiefly annoying as the loss of hair is premature. 
When the loss is asymmetrical, which is decidedly the excep- 
tion, the disfigurement is greater. 

The affection may be circumscribed and in conspicuously 
selected patches where thin, mealy, grayish, or whitish scales 
cover the patch ; or thick yellowish masses may paste the hairs 
firmly to the surface of the scalp. The disease may also extend 
over the entire surface of the scalp uniformly; or, as is fre- 
quently noticed, fringe the brow 7 at the line of the hairs, and 
thence extend chiefly over the vertex, being conspicuous at the 
line where the hairs are parted from vertex to brow r . 

Beneath the scales or crusts of dried sebum, the scalp is usually 
lustreless, and of a slate-gray color. As the disease does cer- 
tainly occur at times in types intermediate between functional 
and inflammatory forms, the subjacent tissues may present an 
hyperaemic or even exudative feature, with true epithelial des- 



286 DISEASES OF THE SKIX. 

qua mat ion nnrl considerable itching. One group of cases, assign- 
able to tlii? class, deserves attention. In them there is a toler- 
ably well-diffused seborrhcea sicca of the scalp, and, here and 
there, irregularly distributed over the surface, are. filbert-sized, 
generally circular, dark-reddish patches, covered with a moist 
secretion or a triable, granular, reddish and yellowish crust. 
These are scalp excoriations produced by the finger-nail. They 
are most common in "nervous" patients, who cannot resist forc- 
ibly digging the seal]) on slight provocation. 

Occurring in infancy, the disease is well known as "milk 
crust " or crusta lactea. This may be merely persistence of the 
dried vernix caseosa about the vertex in the newly born, or it 
may occur in scalps which have been perfectly cleansed after 
birth. The crust differs somewhat in color with the tint of the 
child's complexion ; and may vary from a light yellow to a dark 
brown. It may be thick, greasy, and mat the hairs together ; 
or be thin, dry, and friable. It is a frequent complication of 
the eczematous disorders of this regio/i, and, as a consequence, 
more often in the adult, every variety of hyperemia and inflam- 
mation may characterize the tissue beneath the crust. In in- 
fants and children, however, the resulting alopecia is never per- 
manent, as the rapidly growing follicles hasten to reproduce the 
hair. The disease is also neither contagious nor followed by 
cicatrices, points upon which mothers are usually solicitous. 

The regions of the brow, the surface covered by the beard of 
the male, and the pubic hairs may be involved in the disease. 

Seborrhcea of the non-hairy portions of the body may exist 
upon the face (forehead, cheeks, chin, and nose), trunk, and 
genitals. 

Seborrhcea faciei is characterized chiefly by the accumula- 
tion of thick, dirty -yellowish, and even yellowish-black, accu- 
mulations of sebaceous matter, often adherent to the surface and 
disfiguring the features by the artificial mask produced. This 
is exceedingly conspicuous about the nose, where the disease is 
at times symmetrically disposed. I lately exhibited to the 
medical class at the clinic, a young woman with a complete 
cast, covering the nose uniformly from root to aire, composed 
only of yellowish-gray sebum. Such masses once removed, the 
skin beneath is generally found to be pallid or slightly reddened, 
with the orifices of the sebaceous ducts patulous; while the 
under surface of the separated crust is seen to project downward 
in corresponding delicate prolongations, which Kaposi compares 
to stalactites. The crusts are rapidly reformed when the disease 
is not arrested. They are found in the furrows on either side of 
the nostrils, on the brows, the cheeks, and the pavilion of the 
pinna of the ear. They are most common about the puberal 
epoch in both sexes, when the sebaceous glands of the skin 
undoubtedly sympathize with the changes occurring at the be- 
ginning of the sexual life. 



SEBORRHEA. 287 

Seborrhea trunci is chiefly noted about the clavicles, scap- 
ulae, sternum, and umbilicus. Its features are less pronounced 
than those of some other localities, probably because the friction 
by the clothing, even in persons who neglect the care of their 
skins, serves to stimulate the sebaceous glands of these regions 
to a moderate degree. The disease occurs here in circumscribed 
or, more frequently, illy-defined patches which by confluence 
may describe irregularly-reticulated figures of reddish tint, when, 
as is usually the case, the few loosened fatty plates have been re- 
moved by friction. According to Duhring, who has carefully 
studied these features, the chest patches are circular, pale-reddish 
in color, defined in outline, separate or associated in large groups, 
and covered with withered, greasy, grayish-yellow pellicles, the 
eruption here much resembling ringworm of the body. About 
the umbilicus, the fatty matters are remarkable for their ten- 
dency to speedy decomposition, with the production of an ex- 
ceedingly fetid odor, which may prove to be the source of a 
mild grade of inflammation. In the latter event, a reddened 
halo surrounds the umbilical depression, which may be the- 
source of a thin, sero-purulent discharge. 

Seborrhea genitalium is usually located in the male in 
the sulcus behind the corona glandis, though in individuals 
with a tight or redundant prepuce it may be more extended. 
In the female, the accumulation occurs about the clitoris and 
vestibulum, though the external labia may be covered with the 
secretion in various degrees of fluidity. The smegma preputii, 
supplied by the glands of Tyson, may be thus the source of 
trouble either by its retention, or secretion in abnormal quantity 
or quality. In either event the tendency, as in umbilical sebor- 
rhcea, is to decomposition, fetid odor, and subsequent irrita- 
tion, which may provoke inflammation of severe grade. The 
retention of this smegma beneath a tight prepuce in the male 
may provoke a long list of reflex symptoms, such as incoordina- 
tion of movements in the lower extremkies, nocturnal enuresis 
and pollutions, hernia, and irritability of the testis. In some 
cases the secretion forms a ring as hard as the rind of cheese 
encircling the glans. It should be remembered that the young 
of both sexes as well as adults are liable to be thus affected ; and 
that in young female children these symptoms may have a 
medico-legal interest in connection with suspicion of criminal 
attempts. 

Seborrhoea generalis, affecting the entire surface of the body, 
is an exceedingly rare disorder. It has been described by authors 
as ichthyosis sebacea, cutis testacea and pityriasis tabescentium. 
In the infant, the skin is universally spread with a greasy layer, 
rapidly renewed after removal, beneath which the skin seems to 
be varnished in reddish-brown sbades. The. consequent stiffen- 
ing of the integument produces painful fissures, inability to take 



2K8 DISEASES OF THK SKIN". 

the nipple, and consequent marasmus. In adults, there is noticed 
the same marasmus; with greenish to blackish crusts covering 
the trunk and extremities, mil desquamation of lamellae of the 
Bebaceous accumulation, corresponding, for the most part, to 
regions of the skin mapped out by its normal furrows and folds. 

Seborrhcea Oleosa 

Is in its pronounced features rarer than seborrhcea sicca ; but 
to a less distinct degree is a condition sufficiently common in 
many forms of the disease. Here the sebaceous secretion is 
poured out as an oily fluid upon the surface both of the hairy 
and non-hairy parts of the skin. In the former situation, both 
in adults and' infants, the free oily substance is seen to cover as 
a coating both skin and hairs, and, especially in bald adults, to 
produce a glistening and shining appearance of the scalp. It 
often concretes into masses which are described above as the 
crusts of seborrhcea sicca, The same greasy layer can be seen 
in the non-hairy portions of the skin, especially about the nose, 
forehead, and cheeks. Free drops of oil can be occasionally 
wiped from such surfaces with a handkerchief. The ducts of 
the sebaceous follicles are here either patulous or plugged with 
comedones ; the surface may be reddened or pallid, but is usually 
cold to the touch. The oily substance serves to entrap particles 
of dust, soot, etc., floating in the air, and often thus a peculiarly 
dirty or even blackish hue of the face is produced. Some of the 
forms of seborrhcea described above in connection with the um- 
bilicus and genitalia, are of this variety. In the negro, where 
the sebaceous glands are usually well developed and active, the 
oil}' forms of seborrhcea are common; and the flux, at times, 
almost physiological. Even in the absence of their frequent 
anointing with palm-oil, I have seen the naked blacks in Africa 
with exposed skins shining from exuded grease. 



Etiology. — Seborrhcea may be due to local or general causes. 
This is a point which should be clearly understood, as llebra, 
with his superb powers of observation, noticed that the majority 
of his cases occurred in young male and female subjects affected 
with chlorosis or conditions analogous to that state. It is a clini- 
cal fact of ready verification ; but I am persuaded that many- 
cases are essentially of local origin ; and, as before intimated, am 
convinced that a seborrhcea can be artificially produced in a 
healthy individual in the course of a few weeks by very simple 
local measures without interference with the general economy. 
Females with long hair are usually disposed to take special care 
of the scalp, upon which it grows. Males with short hair are 
more apt to attend chiefly to' its disposition upon the head, and 
to neglect the care of the scalp. For the seborrhcea sicca of 
the hairy parts, I would name neglect of the scalp as the most 



SEBORRHCEA. 289 

frequent cause ; for the same disease of the non-hairy portions 
of the skin, in by far the greater number of all cases, chlorosis, 
struma, malnutrition, obstinate constipation, disorders of diges- 
tion and menstruation, and sedentary habits of life, are unques- 
tionably responsible. The exanthematous and other low fevers 
are often followed by asthenic states in which the same condition 
prevails. Hebra has pointed out the fact that the sebum of in- 
dividuals who have fatty livers from chronic alcoholism, is pecu- 
liarly fluid and oily; and it will be observed that few of all the 
disorders of the sebaceous glands characterized by inspissation 
of the secretion occur in such persons. 

Pathology. — It will be remembered that the sebaceous secre- 
tion is produced in consequence of a fatty transformation of the 
epithelia lining the acini of the sebaceous glands ; it is therefore 
directly derived from the living matter of the protoplasmic ele- 
ments of the rete. A seborrheal is therefore, strictly speaking, 
a catarrh of the epidermis; and the name is in this connection 
properly used, since most of the so-called catarrhs of the skin 
are in reality not such, the effused fluids being furnished by the 
bloodvessels. Typical forms of seborrhcea are strictly anomalies 
of secretion only, unaccompanied by inflammatory processes in 
either the glands or periglandular tissues. While other excep- 
tional forms are without question thus complicated, the varia- 
tions in the sebaceous product as to quantity, inspissation, 
fluidity, tendency to rapid decomposition and exhalation of 
fetid odors, may be due to variability in the transformation of 
the epithelia into fat under the influence of the trophic nerves, 
but this is a matter of conjecture. It is certain that these con- 
ditions are largely under the influence of external agents, such 
as friction, temperature, and air currents. In many cases the 
product of the disorder is composed, for the greater part, of epi- 
thelial masses mingled with a relatively small quantity of sebum, 
thus justifying further the view explained above regarding its 
catarrhal nature. 

The unguents naturally found in excess upon the body or 
parts of it, such as the vernix caseosa, are of course physiological 
in character. 

Diagnosis. — Seborrhcea is to be distinguished from : — 

Eczema. — The objective points of difference between eczema 
and seborrhcea depend upon the inflammatory character of the 
tirst named disease, easily recognized, whether upon the face or 
scalp, by the reddened, infiltrated, or discharging skin, and the 
considerable degree of itching which it occasions. In squamous 
eczema, the scales are rarely so abundant as to be shed freely 
from the surface, and are not greasy. It should be remem- 
bered, however, that the two diseases may and do coexist. 
Eczema of the scalp in infants is especially apt to be accom- 
panied by a seborrhcea, a fact which clearly shows that the 
19 



290 DISEASES OF THE SKIN. 

technical distinctions between many diseases, useful though they 
be for analytical study, arc not always capable of clinical demon- 
stration. 

ICHTHYOSIS. — This is a congenital disease, usually involving 
the entire Burface of the body, while Beborrhoea is generally 
acquired, and rarely universal. The distinction between ich- 
thyosis and the rare generalized forms of Beborrhoea, described 
above, might involve a difficulty. But in the latter, the greasy 
character of the crusts, their color, and the marasmic condition 
of the subject of the disease, would sufficiently distinguish the 
two disorders. 

Impetigo and Impetigo contagiosa. — Here the only possibility 
of error would originate in the discovery of either of the two 
diseases named, in the stage of crusting, especially upon the 
scalp. But both are acute disorders, with crusts much bulkier 
than the sebaceous matters formed in Beborrhoea, and beneath 
such crusts the integument is reddened, and evidently the seat 
of an exudation. 

Keratosis pilaris. — In this disease, also, there is a chronic 
accumulation of matters, partly sebaceous, on the hairy and 
non-hairy portions of the skin. But, unlike Beborrhoea, the 
sebo-epithelial heaps are aggregated in pin head sized masses 
about the hair follicles only, and never accumulate in such 
quantities as to paste the hairs to the surface. The disease is 
also most common on the extensor surfaces of the extremities. 

Lupus erythematosus. — Hebra, in 1845, described a sebor- 
rhea congestiva, which it would be indeed difficult to dis- 
tinguish from lupus erythematosus, as the two are practically 
identical. Typical cases of the two diseases are widely different 
and readily distinguished ; the atypical forms might lead to 
confusion. But lupus erythematosus, though occurring on the 
face, is rare on the scalp; it is accompanied by infiltration and 
the production of a new growth, and is followed by a charac- 
teristic scar. Its lesions are darker red than the congestive 
patches beneath certain seborrheas of the non-hairy parts. The 
scales of lupus are tenacious ami dry, and require scraping for 
their removal ; those of seborrhcea are readily detached, greasy, 
and often cover the shoulders of the patient. The contour of 
the seborrheic patch is illy defined, while that of lupus is very 
distinct, exception being made of the mask-like crusts seen in 
certain of the facial seborrheas when the greasy character of 
the layer is very evident. Lastly, seborrhoea is a disease of 
puberty chiefly, while lupus erythematosus is likely to be first 
seen in the earlier years of childhood, when facial seborrhea 
is rare. 



SEBORRHCEA. 291 

Psoriasis. — Psoriasis of the scalp may resemble seborrhcea 
sicca. But the latter is rarely developed in such a universal 
exanthem as is frequent in the former. Few doubtful cases 
will come under observation, when a psoriasic patch on the 
elbow, knee, leg, or sacrum, will not point to the nature of the 
disease. The scales of psoriasis are lustrous, larger, and not 
greasy, unless fatty applications have been made to soften them; 
and they cover, moreover, a reddened and exuding patch of 
integument. Psoriasis of the scalp and face prefers the areas 
of the forehead adjacent to the hairs of the scalp, and rarely 
departs boldly to the nose and the furrows beside the nostrils, 
favorite sites of a seborrhoea. 

Syphilis. — Some forms of the pustular syphilodermata located 
upon the scalp and face, if observed only in the stage of crust- 
ing, might be confounded with seborrhcea. Here the history of 
the case, the discovery of other signs of syphilis (adenopathy, 
mucous patches, etc.), and the puriform character of the secre- 
tion beneath the crust, should point to the identity of the dis- 
ease. In syphilitic crusts about the angles of the nostrils, there 
is often a peculiar reddish-brown tint of the skin at the edge of 
the patch, the so-called "copper" color, which is significant. 
Crusts of the hairy scalp in syphilis are very often accompanied 
by post-cervical adenopathy, and especially by indurated enlarge- 
ment of the occipital glands. 

Tinea circinata and T. tonsurans. — In ringworm of the hairy 
parts, as also of the body, the microscopical discovery of the 
parasite will always point to the nature of the disease. Upon the 
scalp, the affected patches are seldom as diffuse as in seborrhcea; 
are usually circular; are often accompanied by fragility of the 
hairs ; and, in the latter case, the discovery of stumps of hairs 
is significant. There is also a history of contagion and absence of 
the greasy conditions .of the scales, characteristic of seborrhoea. 



Treatment. — The indications to be met by local treatment in 
seborrhoea are : first, the removal of the crusts and fatty mat- 
ters accumulated upon the surface ; second, the restoration of 
the deranged function of the glands. 

Upon the scalp, it is always well at the onset to warn pa- 
tients, especially if the disorder is aggravated and occurs in 
young females with apparently luxurious tresses, that a consid- 
erable loss of hair will result. Many of the latter are so im- 
poverished by the chronic course of the disease, and so loosened 
in their follicles, that a complete cleansing of the scalp surface 
will bring them away in quantities sufficient to threaten a speedy 
baldness ; and it is not rarely the case that patients attribute 
this to the treatment rather than to the disease. The fatty 
accumulations are first to be soaked in some oily fluid to facili- 



292 DISEASES OF THE SKIN. 

tate their removal ; and for this purpose olive oil, cod-liver oil, 
or lard are usually employed. The article selected should be 
used in excess and iii quantity sufficient to permeate ;ill crusts. 
It may be poured over or rubbed into the seal)) several times in 
the twenty-four hours; and at night a flannel or other cap be 
worn to still further insure success. In the case of children and 
infants, considerable gentleness is required in thus treating the 
Bcalp, especially in the subsequent washings, lest the surface be 
irritated. In young women, it is rarely necessary to cut the 
hairs. As soon as the soaking with oil is insured, the crusts 
are to be removed by washing with soap and water, though 
when the accumulations are bulky, masses may be gently re- 
moved with fingers or comb. When the scalp is quite tender, 
ordinary toilet, or Sarg's imported glycerine soap, may be ap- 
plied with warm water; but it is usual in the case of adults to 
employ the spiritus saponis kalinus, of Hebra, two ounces (60.) 
of green soap digested in one (30.) of alcohol, filtered and flavored 
with lavender or bergamot. The surface should be thoroughly 
sponged with the spirit, and then warm water added till the 
foam of the lather is abundantly produced over the scalp, when 
an excess of water is finally used to cleanse the part of both 
crusts, oil, and soap. The scalp and hairs are then thoroughly 
dried and anointed with some bland, fatty substance if the sur- 
face exposed is tender and irritable; if not, with some stimu- 
lating pomade. 

The last-named precaution is an important one. However 
extensive the seborrheic crusts, it is possible to remove these 
complete^ by the measures described above in every case; and 
with the first experiment patients are often delighted. Their 
disappointment is correspondingly great when they discover that 
the seborrhcea is not yet at end, and that, in the course of a few 
days, the fatty plates are as freely as ever deposited on the 
scalp, disseminated through the hairs, and showered upon the 
shoulders. Some will even declare that .the soapy applications 
aggravate the disorder by increasing the seborrhcea. It should 
therefore never be forgotten, that having got rid of the extra- 
neous matters accumulated upon the surface, there is still to be 
remedied a functional disorder of the sebaceous glands of the 
part. 

In every case, then, after the use of the soap and water, which 
may be repeated as often as need be, daily, at intervals of several 
days, or once in the week, the scalp is to he thoroughly anointed. 
For this purpose olive oil, cod-liver oil properly scented, almond 
oil, vaseline, or glycerine and water, may be used. In the course 
of a few days, in most instances, a more stimulating plan of 
treatment may be adopted; and, in that event, alcohol may be 
combined, for example, with the oil of sweet almonds, half an 
ounce (16.) of the latter to five ounces (160.) of the former, to 
which half a drachm (2.) of carbolic acid may be added, the 
whole flavored with the oil of bergamot. 



SEBORRHEA. 293 

Repeated applications and patient care of the scalp are neces- 
sary to secure complete relief' in the case of a disease as essen- 
tially chronic as seborrhcea. At times the local treatment may 
be changed with advantage. Sulphur enjoys a high reputation 
in the treatment of all sebaceous gland disorders; and in the 
form of an ointment, one to two drachms (4.-8.) to the ounce 
(32.) of cold cream, it is often of service. I have used with 
success the hypochloride of sulphur, which has lately come into 
our markets from the English laboratories. But it is open to 
objection on account of its odor, which can scarcely be disguised. 
Besides these, the tinctures of cantharides, capsicum, and nux 
vomica are frequently incorporated with advantage into lotions 
and pomades for use upon the scalp. Most of the latter can be 
made sufficiently fluent for use in this situation, by adding a 
drachm (4.) or two (8.) of glycerine to the ounce (32.) of lard or 
cold cream. The alterative effect of the mercurials is also as evi- 
dent here as in many other cutaneous disorders. At the head of 
the list, for this special purpose, stands the red oxide of mercury 
in the strength of from two to four grains (0. 133-0. 2t>6) to the 
ounce (32.) of ointment; but the white precipitate, the ammo- 
niated mercury and calomel, in the proportion of five to ten 
grains (0.333-0.666) to the ounce (32.) may be often substituted 
for the former with advantage. Solutions of corrosive sublimate, 
in the strength of two to four grains (0.133-0.266) to the ounce 
(32.) of fluid, may prove of use in obstinate cases. Hillairet 
recommends a lotion containing from two to four fluidrachms 
(8.-16.) of sulphuric ether and two to four drachms (8.-16.) of 
borax dissolved in eight fluidounces (256.) of distilled water. 

The treatment, described in outline above, may be used with 
success also for the relief of seborrhcea of the non-hairy portions 
of the body, especially the face. Here, it will be observed, the 
crusts have a singular tendency to re-form; and the most per- 
sistent care is necessary to secure permanent relief. Occasionally, 
after cleaning the surface by soap and spirit lotions, according 
to the indications of each case, it may be of advantage to apply 
the ointment selected for subsequent application, not only by 
gently smearing it on the part with the tips of the fingers 
(always the most effective method), but also by spreading it on 
a compress, which, for the night at least, may be fixed in con- 
tact with the part. When this tendency to re-formation of the 
crust is abated, one or more of the dusting powders may be at 
times employed with advantage for the purpose of protecting 
the skin or exercising upon it an astringent effect. 

The local treatment of seborrhcea of the genitals is somewhat 
different. Ointments rarely answer well in disorders of the 
mucous surfaces; and the green soap is too irritating for similar 
employment. Here washing with a good toilet soap and warm 
water is sufficient for the purposes of cleanliness, and diluted 
lotions containing alcohol, in the form of whiskey, brandy, or 
aromatic wine, suffice to procure relief. These can be made 



204 DISEASES OF THE SKIN. 

astringent with tannin, alntn, or the zinc sulphate, and, when 
there is pain or tenderness, opium can be added. In this form 
of the disease, as also in seborrhcea of the umbilicus, carbolic 
acid or the chlorinated soda may be necessary to correct fetor. 
In the generalized varieties of the disease the surface is to be 
thoroughly anointed with oil. The body, especially that of 
infants, is to be swathed in flannel or other good non-conductor 
of heat: and a roborant treatment directed to the general ady- 
namia. 

The internal treatment of seborrhoea is often of the highest, 
importance. The preparations most often indicated are: Iron 
in anaemic yount; women; cathartics in sluggishness of the 
bowels; and cod-liver oil when there is impairment of nutrition. 
Duhring recommends the sulphide of calcium in doses of from 
one-tenth (.0066) to one-fifth (.0133) of a grain. Arsenic, em- 
ployed in the manner suggested by Sir Erasmus Wilson, is 
praised by Hebra: — 



. Vin. ferri 


fijss ; 


501 


Syrup. si m pi. ) 
Liq. potass, arseuit. ) 


aa f"3ij ; 


8 


Aq. destill 


fSU; 


60 



M. 

S. A teaspoonful to be taken three times daily with the meal. 

The preparations of malt and maltine, now largely employed 
by the profession in the treatment of wasting diseases, will be 
found available in eases where the cod-liver oil cannot be well 
taken. Lastly, the bitter tonics may be needed. Throughout 
the treatment, the physician should insure a careful observance 
of the laws of hygiene. Sunlight, nutritious food, and open air 
exercise are not to be disregarded. In the large cities of this 
country, many young women of indolent habits are greatly 
benefited by sending them to the riding schools for an hour's 
equitation daily. 

Prognosis. — In forming a prognosis in cases of seborrhcea, it 
must be remembered that the disease is frequently an obstinate 
one ; and the resulting loss of hair, if symmetrical, may be reme- 
diless. Much may be done in the way of saving that which is 
left. Facial seborrhoea is much more amenable to treatment ; 
and seborrhoea of the genitals and umbilicus is an entirely man- 
ageable disease. When the affection is generalized, the prog- 
nosis is in the highest degree unfavorable. 

Comedo. 

Comedo is a disease in which an inspissated secretion, lodged in the excretory 
ducts of the sehaceous glands, becomes visible upon the surface in yellowish- 
white or brownish-black points. 

Symptomatology. — Comedones occur exclusively in the ducts of 
the sebaceous glands, and consist of a whitish fatty plug formed 
by the inspissation of the secretion of these glands, one extremity 
of which is visible at the surface when the plug is in situ. Oc- 



COMEDO. 295 

casionally they project to an appreciable distance above the 
general level of the integument; but often careful inspection 
will suggest that the extremity of the plug is slightly depressed 
below that level. There may be but two or three upon the face, 
which is their most common seat, or the nose, forehead, cheeks, 
chin, the front and back of the neck, and the back of the trunk 
and the penis may be thickly studded with them. The visible 
extremity of the comedo varies in size from a needle-point to a 
pin-head. They are readily expressed from the follicles in which 
they are lodged, and when thus examined are seen to be whitish 
moulds of inspissated sebum, one to two lines in length, the ex- 
posed extremities of which have become blackened by the dust 
and dirt entrapped at that point. In consequence of this sugges- 
tive appearance of the mass, the disease has been vulgarly known 
as "black heads" and "skin worms." The deformity produced 
in the face when these lesions exist there in large proportions, 
is strikingly conspicuous; and it is for the relief of this chiefly, 
that the practitioner is consulted. The subjective symptoms 
awakened are of trifling moment. The disorder is essentially 
chronic in its course. Isolated comedones may be observed for 
years in one situation without apparent change or modification 
of any sort, and without producing the slightest local or consti- 
tutional derangement. Others appear, only to disappear under 
the influence of the usual hygienic regimen of the skin of the 
face. Others again serve to irritate the skin in which they are 
implanted, precisely as though they were foreign bodies; and 
the sebaceous glands and peri-glandular tissues, with and without 
the operation of such cause, exhibit grades of hypersemia and 
inflammation. Comedones may occur as the sole lesions of the 
skin, even to the extent of very great multiplicity ; or they may 
coexist with other diseases of the glands, chiefly acne. They 
may occur at any period of life, but, like seborrhcea, are most 
frequently observed at the puberal epochs in both sexes. Ac- 
cording to Kaposi, the disease tends to disappear in the female 
earlier than in the male, in whose case it may be prolonged to 
the twentieth or thirtieth year. 

Etiology. — Much has been written with reference to the im- 
proper care of the skin as a cause of comedo, the neglect of soap 
in washing the face, and the influence of the trades, as in the 
case of those who work in metals, dust and tar. But observa- 
tion shows that these are exceptional causes. I have seen very 
obstinate and generalized lesions in the skin of intelligent young 
men and women of the upper social classes, who regularly washed 
their faces with toilet soap, were rarely exposed to dust, and 
whose habits and recreations were of the most healthful character. 
Similarly I have for some time past observed the grimy faces of 
coal heavers, machinists, masons, and certain ink manufacturers, 
and have been impressed with the singular rarity of the disease 
in such laborers. The cause of the disease is unquestionably to 
be sought for in the gland itself. It is true that young chlorotic 



!_".<.; 



DISEASES OF THE SKIN". 



females, affected also with dyspepsia and constipation, may ex- 
hibit the disease ; ;ui<l equally certain that many of the moderate 
cases occur in peculiarly thick-skinned brunettes, or men with 
a characteristic reddish-brown and greasy-looking complexion. 
Bur tor all this, many bucIi never suffer From comedones, while 
often a perfectly healthy, fair-skinned girl will be greatly morti- 

Piz. 34. 




<^>* 



n't,: 



d__. 










^■^■'-V%j:;: ;■'■,'.''■:'' 



Section of a comedo, a, excretory dnct of a sebaceous gin nd filled with a comedo ; it contains 
also two small hair* with brush-like inferior extremities. : into it open* a small hair-follicle, c, 
whose contained hair, </. after touching the opposite wall of the excretory duct of the sebaceous 
gland, curves downwa d at /. (After Kaposi.) 



tied by the disfigurement of her face. The causes of the gland 
inaction are then, in many cases, of local significance, and ob- 
scure as to origin. These local disorders are often as inexplicable 
as an attack of pharyngitis sicca, caries of a molar tooth, or a 
14 soft corn." 

Pathology. — The mass termed the comedo is a collection of 
epithelial plates mingled with masses of eluilesterine, fragments 
of epithelia undergone fatty transformation, minute lanugo hairs, 
and, occasionally, upon the exterior, the acurus follicalorum. This 
little mite, first detected by Ilenle, in the ceruminous glands, 
was by Simon and others once thought to be the cause of the 



COMEDO. 297 

comedo, a view which is now abandoned by all dermatologists. 
The parasite, in persons upon whose skin it exists, can be de- 
tected in masses of commingled sebum and epithelial plates 
scraped from the free surface of the integument, as also upon the 
surface of those who do not exhibit any disorder of the sebaceous 
glands. The comedo plug is located either in the excretory duct 
of the sebaceous gland or in the pouch shaped canal common to 
the sebaceous gland and the hair-follicle. It will be remem- 
bered that in the class of sebaceous glands chiefly involved in 
the comedo, the hair follicle is rather an appendage to the 
former, the relation between the two, evident upon the scalp, for 
example, being here reversed. According to Biesiadecki, the 
hair follicle often forms here an obtuse or even a right angle 
with the duct of the gland, and the point of the hair being thus 
projected against the wall of the duct, is occasionally curved 
downward upon itself, exciting thus an irritation at the point 
of impact, and subsequent multiplication of the protoplasmic 
elements lining the canal. Thus he explains the epithelial 
character of the outer envelope of the plug, the special occurrence 
of the disease at the puberal epoch, when, as is well known, 
there is an especially active growth of the hairs; and, lastly, 
the frequent discovery of lanugo filaments in the expressed con- 
tents of the common excretory duct. 

Diagnosis. — The recognition of the disorder is attended with 
no difficulty, patients themselves being usually sufficiently ob- 
servant to identify the affection, though frequently misled as to 
the character of the " skin worm." It is, as might be expected, 
a frequent coincident of acne; its lesions, when commingled 
with those of the disease last named, being either in preponder- 
ance or so infrequent as scarcely to attract the attention of the 
patient. A condition somewhat resembling the comedo may be 
produced upon the face when ointments of mercury and sulphur 
are applied to it at the same time, the resulting black sulphuret 
appearing conspicuously at various points upon the skin, often 
at the orifices of the sebaceous glands. 

Curiously atypical cases, however, are occasionally observed, 
and these might confuse one unfamiliar with the singular va- 
riations displayed in almost all sebaceous gland disorders. Thus 
Cauty 1 reports a remarkable case of a boy ten years of age, who 
was somewhat imbecile, but well nourished. The upper part 
of the back, both shoulders, and the outside of both arms were 
covered with short bristles, of a clear, darkish brown-yellow 
color, and acuminated apices. These bristles were, at the edges 
of the group, gradually shortened from their full length of three 
thirty-secondths of an inch, until they joined the skin, which 
was at the junction raised into polygonal, fiat disks, finally 
graduating to the sound integument of the hands, chest, and 
back. The feeling communicated to the hand on passing it over 

1 Medical and Surgical Journal, March 4, 1882, p. 237. 



208 DISEASES OF THE SKIN*. 

the shoulders was exactly similar to that of touching a coarse 
brush, and the bristles gave way under the touch, resuming an 
upright positron afterward. There were a few pink maculae 
over the body, and considerable scaly thickening on and around 
the patellas. The bristles were expelled comedones, containing 
very tew immature hairs and very little sebum, drying up into 
a horny substance. They were firmly attached, requiring more 
force to remove them than to extract a well-rooted hair ; and 
when removed they left a small, central depression, surrounded 
by a circle of torn epithelium, which retained them in position. 
They averaged one hundred to the square inch, and hud existed 
over three months. 

Treatment. — Even aggravated cases of comedo are completely 
relieved by natural processes in the course of time. These pro- 
cesses are, however, slow, and may require years for their com- 
pletion. The rarity of comedo-stuffed faces in middle life and 
advanced years sufficienth 7 attests this fact. Presumably this 
natural cure is due to the more vigorous growth of lanugo hairs 
with the increment of age, which "thus push forward slowly to 
the surface the excrementitions mass, until it is gradually re- 
moved by ordinary friction and ablution. Absence of comedones 
from the scalp, where the hair is vigorous, is certainly a signifi- 
cant fact. 

Rapid relief of comedones is affected by removal of the plug. 
The instrument in common use for this purpose is called the 
comedo-extractor. It is shaped like a watch kej:, has a smooth 
and circular bore:; and the edge of the cylinder which surrounds 
the bore is smooth and beveled so as to inflict the slightest 
degree of injury upon the skin about the gland orifice. The 
cylinder should be open above, near the handle of the key, to 
facilitate the removal of the sebaceous material with which the 
key is soon stuffed. Some are made with a graduated and 
sharpened needle, operated as a piston through the handle of 
the instrument, a device open to many objections. A needle is 
often used witli advantage for the purpose of opening the duct 
or dislodging its contents; but this can be employed separately 
when it can be guided by the eye with greater advantage. 

The skin having been previousl} 7 softened by sponging with 
water as hot as can be borne with comfort, the extractor is ap- 
plied over the orifice of the duct, and usually by gentle pressure 
the plug is felt to slip into the little tube. The indentation of 
the skin left by the instrument at the point of its application is 
usually removed in the course of a brief time. Wigglesworth, 
having this in view, suggests the performance of the operation 
at night ; and there are other good reasons for selecting the hour 
before retiring as the time for all vigorous topical applications 
to the face. Ointments then applied can be left in contact with 
the skin during the hours of sleep, and the patient is at liberty to 
resume his usual avocations it) the daytime with his face free 
from conspicuous evidence of being under treatment. These 



COMEDO. 299 

remarks are pertinent also to the case of the patient affected 
with acne. 

An ordinary watch-key, the thumbnail, or a spatula are -also 
at times useful in the extraction of comedones, which may be, 
if few, removed all at one sitting, or, if numerous, on separate 
occasions. Repetition of the process may be required by the 
re-formation of the plugs. Once they are removed, the skin 
should be again sponged and bathed with hot water, then thor- 
oughly dried, and anointed with an ointment which may be 
medicated to suit the indications of each case. Sulphur, as in 
all the functional disorders of the sebaceous glands, enjoys here 
also the highest reputation. In the strength of one-half to one 
drachm (2.-4,.) to the ounce (32.) of cold cream or vaseline, it 
may be applied as an ointment, or as a lotion, in combination 
with spirits of wine, glycerine, etc. I have frequently used with 
advantage the mild application suggested by Piffard in acne, 
equal parts of sublimed sulphur, alcohol, compound tincture of 
lavender, glycerine, and camphor water. 

Mercurials are also of -some advantage locally, and, as before 
indicated, should not be employed at the same time with prepara- 
tions of sulphur. The use at night, especially in obstinate cases, 
of the white precipitate ointment, or one compounded of two 
grains (.133 s ) of the red oxide to the ounce (32.) of cold cream 
will often prove- •of benefit. One to two grains (.066 to .133) of 
corrosive sublimate to the ounce (32.) of glycerine and rose- 
water may be substituted for the latter in coarser skins. 

When the extraction of the plug is not attempted nor permit- 
ted, something may yet be done to remove the inspissated mass. 
Repeated sponging every third night with one ounce (32.) of the 
green soap, digested in an equal quantity of Cologne water, will, 
at first certainly, seem to render the comedo more conspicuous, 
but will slowly operate to dissolve the sebaceous secretion. 

Uuna, however, has lately observed that the blackish dis- 
coloration of the comedo extends to a certain degree below the 
external extremity of the plug, a circumstance, in his opinion, 
militating against the dust and dirt theory, by which the hue of 
the comedo point has been explained. He concludes that this 
is the result of pigmentation, such as that producing the color- 
ation of the hair, nails, and skin in several other anomalous con- 
ditions. Having this in view, he prescribes an ointment con- 
taining four parts of kaolin, three of glycerine, and two of acetic 
acid, with or without the addition of a small quantity of ethereal 
oil. This is applied at night, the eyes being carefully closed, 
for a few nights in succession, when the black points of the 
lesions are removed, and the comedones then readily extracted. 
Citric or dilute hydrochloric acid is employed, with the same 
end in view. I have employed this formula in about fifteen 
cases, with varying results. It cannot be considered as efficient 
in every form of comedo. 

Actors, actresses, and women of fashion will occasionally per- 



800 DISK ASKS OF THE SKIN. 

sist in using variously colored toilet powders while under treat- 
ment, the injurious ingredients of which are often the cause of 
the disease. The practitioner may then either refuse to be re- 
sponsible for the cure <»f the case; substitute a harmless for a 
noxious powder; or gently anoint the face after his treatment of 
it with a bland ointment, upon the surface of which the theatrical 
effects art' subsequently produced. In such cases the use of soap 
an 1 water with each dressing is even more than usually imper- 
ative. 

The internal treatment of the patient affected with comedo 
is largely that described in connection with the subject of 
seborrheal. Cod-liver oil, iron, the bitter tonics, and prepara- 
tions indicated by any special condition of the patient's health, 
arc not to he omitted. Open-air exercise, bathing, and the 
avoidance of all medicinal and dietary articles, which might 
tend to aggravate the disorder, are also imperative. 

Comedones of the penis should not he treated. This injunc- 
tion is suggested by the occasional demand made upon the 
physician by the sexual hypochondriac, who regards these lesions 
with a decree of alarm which lie can best appreciate who has 
been confronted with these cases. 

Prognosis. — As the disease tends naturally to a spontaneous 
though occasionally long-deferred resolution, the prognosis is 
always favorable. Treatment in many cases will accomplish 
much in hastening the result. The most obstinate forms are 
those in which the face, back of the ears, neck, and shoulders 
are studded with relatively small, indolent comedo points, about 
which the oritice of the duct rises in a whitish rim. This, when 
felt with the finger, produces the impression of hyperplasia of 
the wall of the duct. Such cases, however, are nearly allied to 
the forms of acne to be described later. 

Sebaceous Cysts. 

The term sebaceous cyst is applied by several authors to one 
merely of the two disorders of the skin to which it properly 
belongs, viz., the wen or atheroma. In these pages it is 
employed in a generic sense, and thus includes both milium 
and wen. 

Milium. 

Deriv. Lat. milium, a millet-seed. 
Milia are encysted tumors of the sebaceous glands, represented by millet-seed 
to pin-head sized, milky-white, or yellowish-white bodies, either embedded 
within the epidermis or projecting slightly above it. 

Sy iiplomatology. — Milia occur upon and about the eyelids, the 
cheeks, the temples; the penis, scrotum, and corona glandis of 
the male; and the internal face of the labia minora of the 
female. They are recognized as millet-seed to piu-head sized 



SEBACEOUS CYSTS. 301 

globoidal masses, rarely attaining the size of a coffee-bean, 
showing within the epidermis as though kernels of rice were 
there lying immediately beneath a translucent layer of tissue. 
They occasionally project from the surface to such an extent as 
to resemble small-sized vesicles tilled with milky contents. In 
color they are yellowish and whitish. They are often congeni- 
tal ; and can be recognized about the lids and temples of the 
newly-born infant; they are also seen, however, in middle lite, 
when they develop very slowly, and sometimes persist for years. 
They are often observed in the neighborhood of cicatrices, which 
latter in such case htive usually been effective in their produc- 
tion. They occasion no subjective sensation, and are usually so 
insignificant as to induce no deformity. They never degenerate 
by ulcerative processes, but when not artificially removed are 
generally, in the course of years, exfoliated in the natural pro- 
cesses of physiological desquamation. 

Etiology. — Milia are at times produced mechanically, the stroke 
of a knife blade, accidentally or by the processes of surgery, sepa- 
rating one or more of the acini of a sebaceous gland from the 
main body. The contracting bands of a cicatrix, after the de- 
struction of tissue from any cause, may operate in a similar way 
with a precisely similar result. Having this in view, it may be 
said generally that milium is always the result of a cause which 
prevents the transformation of the epithelia lining the gland 
into fat, and the subsequent excretion of this upon the free sur- 
face of the skin. These causes are thus, for the most part, ob- 
scure, but all are probably of purely local significance. 

Pathology. — When a milium is incised externally, a spherical 
body of nearly corresponding size may be expressed, though it 
may require tearing from a minute pedicle below, which repre- 
sents the attachment to the hair follicle. The small mass thus 
extracted is then seen to be composed of several thin envelopes 
suggesting the capsules of the onion, and representing cornified 
epithelia not undergone fatty metamorphosis, in the centre of 
which is a fatty nucleus. This mass represents the contents of 
one or more acini of a superficially situated sebaceous gland, cut 
off' from the main body or the hair follicle in the manner de- 
scribed above, ancl always covered when in situ, as Kaposi has 
shown, by a delicate layer of the superimposed corium contain- 
ing papillae. Usually the orifice of the excretory duct cannot 
be appreciated in milia, though occasionally these lesions are 
developed when the orifice is patulous. 

These singular bodies do not always represent conditions of 
mechanically pent-up sebum, as the epithelia from which their 
contents are produced seem at times indisposed to fatty trans- 
formation and particularly apt to develop into horny or other 
formations. Thus Foster, of Boston, describes one where the 
process of calcification had been apparently complete; Wagner 
has observed colloid contents in certain opalescent lesions which 



302 DISEASES OF THE SKIN. 

appeared in the cheeks and temples of a woman ; Barensprung 
and Hebra report numbers of acutely produced milia following 
pemphigus and erysipelas; and \Tirchow and Rindfleisch de- 
scribe milia of the hair sac and similar lesions accompanied by 
cyst of the hair follicle adjacent. It would seem rational to 
conclude that, in cases, the cause of milia is to be sought in 
obscure changes, by which the epithelia of the gland are pri- 
marily affected. 

Diagnosis. — Milia might be mistaken for minute vesicles con- 
taining a milky fluid, but puncture of the lesion, with expulsion 
of its contents, would at once disclose the character of each. 
Comedones with blackish external points, surrounded by the pat- 
ulous orifice of the excretory duct and prolonged more deeply into 
the substance of the skin, could scarcely be confounded with 
milia. 

7V< atment. — Milia rarely require treatment, as they are usually 
relatively tew in number, and occasion neither subjective sensa- 
tion nor deformity. If desirable, they may be opened with a fine- 
bladed bistoury, and their contents turned out. To insure their 
non-recurrence, the little sac left after the operation may be en- 
tered with a needle dipped in a fifty per cent, solution of chromic 
acid. This operation may have to be repeated in the rare cases 
where the lesions exhibit a special tendency to recur. 

Wens. 

Wens are encysted sebaceous tumors larger than milia, usually covered by an 
integument of normal color. 

Symptomatology. — The history of the development and career 
of wens, or, as they are sometimes called, sebaceous cysts, does 
not greatly differ from that of milia, already described. They 
are usually slow of growth ; unattended by subjective sensation ; 
occur as single or multiple tumors on the head, trunk, or geni- 
tals ; and, being larger than milia, may attain the size of a hen's 
egg. They are situated beneath, within, or upon the skin ; are 
usually unattached to the deeper contiguous tissues; and de- 
velop into irregularly globular, occasionally large button-shaped, 
masses, covered by an integument usually unprovided with hairs. 
This envelope may be quite normal in hue ; or unnaturally whit- 
ish from pressure; or, especially upon the bald scalp of certain 
fleshy men of middle years, reddened, shining and greasy in 
appearance. At times they are to be distinguished only by 
passing the fingers through the long hairs of the scalp beneath 
which they are hidden; at others, they are so conspicuous in 
consequence of alopecia as to occasion considerable disfigure- 
ment. They vary greatly in consistency, but usually produce 
to the touch a certain feeling of elasticity, especially if the cyst 
be tensely distended. They are rarely attacked by inflamma- 
tion, resulting in suppuration and ulceration. 



SEBACEOUS CYSTS. 



303 



Fte. 35, 




Sebaceous tumor of the scalp, one of them 
being laid open to show its cysts and con- 
tents. (Gross ) 



Pathology. — Wens represent an advanced grade of distension 
of the sebaceous glands by their contents, and a response to the 
consequent pressure in hypertro- 
phy of the glandular envelope. 
Their contents are serai -solid,, 
curdy, cheesy, and granular; or 
fluid and milky; or fluid and pur- 
ulent. These are the inspissated 
or chemically altered products of 
the gland secretion, recognizable 
as such by the materials of which 
they are composed, masses of fat 
and debris of epithelia, with an 
occasional lanugo or undeveloped 
hair. 

Diagnosis. — Wens are to be dis- 
tinguished from fatty tumors, 
which, however, are more com- 
monly observed about the scapulae, 
loins, buttocks, and extremities; 
while wens are very rare except 
about the scalp and neck. They 
lack also the peculiar "• pillowy" 
feel of fatty tumors. Suppurating 

wens in these regions may readily be mistaken for circum- 
scribed abscesses, if regard be not had for the history of the 
tumor usually long preceding. Syphilitic nodes of the same 
part are usually both tender and painful; osteomata are also 
firmly attached. 

Treatment. — The removal of wens usually falls within the 
province of the surgeon, and is accomplished by excision, after 
previous puncture of the sac and the removal of its contents. 
Several fatal cases, however, are on record as the result of this 
operation ; due not so much to the nature of the excised tumor 
as to its situation, surgical wounds of the scalp being particu- 
larly liable to erysipelatous and other complications. As the 
incision required for the removal of the wen must necessarily 
extend for some distance on either side of the tumor, a linear 
scar results which on the bald scalp is often very conspicuous as 
a relic of the lesion. In consequence of the possibility of danger, 
many surgeons prefer destruction of a prominent section of the 
mass with acid or alkali, leaving the sac after expulsion of its 
contents, to gradually wither, though it may then be often with- 
drawn by forceps. Complete obliteration is sometimes effected 
by puncture, expression of contents, and the subsequent induc- 
tion of artificial inflammation in the walls of the cyst by injec- 
tion of irritating fluids, as in the operation for the relief of hy- 
drocele. 



304 DISEASES OF THE SKIN'. 

Asteatosis. 

Derir. Gv. a, privitive ; a-tIm, fat. 

Asteatosis is that condition of the skin in which there is absolute or relative 

deficiency of the sebaceous secretion. 

Symptomatology. — Insufficient lubrication of the skin by its 
natural unguent may be cither general or partial, and occur 
either as an idiopathic or symptomatic disorder. It is produced 
artificially by any agents which continuously withdraw the 
fatty substance from the skin surfaces, as in those trades neces- 
sitating the constant immersion of any parts of the body in 
strong alkaline solutions, or waters highly impregnated with 
the sails of lime and potash. As an idiopathic affection, it is of 
very rare occurrence, hut it is not an infrequent accompaniment 
of other local or constitutional diseases, such as psoriasis, lepra, 
xeroderma (of Ilebra), ichthyosis and lichen ruber. In these 
ea^es the skin becomes dry, often thickened and indurated, and, 
as a consequence, friable, prone to desquamation, fissures and 
chaps. When handled, the absence of sebaceous secretion is 
noticeable in the objective sensation produced. It is a well- 
marked feature in the marasmus of old age. Some authors have 
described, under this title, the dry thickening and induration 
of the palm of the hand, accompanied by curving of the fingers 
toward the plane of their flexor tendons which is occasionally' 
to be observed among laundresses. But considering the absence 
of sebaceous glands from the palm, where in my experience this 
affection is most pronounced, it should be properly excluded from 
the list of sebaceous disorders. (See Eczema of the hand.) 

Treatment.— No internal medicaments are known to have the 
power of stimulating especially the sebaceous secretion. None, 
indeed, could be capable of having such action when, as is often 
the case in the disorders described above as characterized by 
asteatosis, there has resulted an atrophy of the sebaceous glands. 
The most that can be accomplished is the external application 
of an artificial unguent ; and for this purpose cod-liver oil, 
almond oil, palm oil, vaseline, lard, or butter may be employed. 
Vaseline is in many cases to be preferred, as the other articles 
named are liable to become rancid after oxidation, and thus act 
as irritants to the skin. With such partial or general lubrica- 
tions, however, a warm bath with soap and water should be 
ordered every second or third day, immediately after which the 
inunction may be repeated. 

Prognosis. — In all those cases where the asteatosis is induced 
b\- agents operating externally upon the surface, a reasonable 
hope of recovery may be entertained after the withdrawal of 
the cause. Persistence of the latter is liable to be succeeded by 
the occurrence of eczema or dermatitis medicamentosa. A com- 
plete cure can scarcely be expected when this condition is really 
a symptom of one of the disorders already named. 



ACNE. 305 



2. Exudative. 

Acne. 

Deriv. Gr. ««b, a point. 

Acne is an inflammatory disease of the sebaceous glands, in which appear 
usually multiple, and painful, firm, reddish, pin-head to small nut-sized nod- 
ules, which may result in suppuration and the formation of cicatrices. 

Symptomatology. — Acne is probably the cutaneous disease of 
most common occurrence, not excepting eczema. The latter 
affection occurs upon the face as often as upon other parts of 
the body, and is yet seen upon the street with far less frequency. 
Eczema, however, is more distressing; in its symptoms, and for 
that reason physicians are more often consulted for its relief, 
the disease thus acquiring a statistical preponderance. Acne is 
more tolerable, and therefore more tolerated and less treated, 
especially among the poor. 

The disease is characterized in general by the occurrence of 
several and usually numerous, light-red, dull-crimson, or viola- 
ceous, pin-head to small nut-sized, circumscribed, illy defined 
papules, nodules, tubercles, or non-projecting indurations of the 
skin, often commingled with the lesions of comedo and sebor- 
rhea sicca. They are usually both slightly painful and tender, 
though upon this point there is a wide range of difference in 
different individuals, some patients tolerating with a surprising 
equanimity the most extensive invasions of the disease. The 
inflammatory process, which manifestly involves' the sebaceous 
glands and periglandular tissues, may result in suppuration of 
one or several adjacent follicles, as a consequence of which co- 
alescence and pea- to large nut-sized, cutaneous and subcutaneous 
abscesses may form. In the larger number of cases, however, 
the suppuration is limited to the area of the individual nodule, 
every feature of the entire process being displayed at the same 
moment in an affected individual. Under circumstances of spe- 
cial aggravation, the disease may occur in acute forms, but it is 
commonly chronic ; and such acute phases are usually accidents 
of the general process. 

The disease occurs chiefly upon the face, but is also seen upon 
the neck, the back, and front of the chest, the genitals, and the 
extremities, the palms and soles alone excepted. It is emphati- 
cally a disease of the early puberal epoch in both sexes, though 
occasionally seen in middle and later life. It usually lasts, when 
unrelieved, for years, being during this period suhject to occa- 
sional exacerbations and remissions; but commonly sponta- 
neously disappears as the full maturity of the body is at- 
tained. In severe cases, it leaves indelible traces of its ravages, 
in the scars where suppuration has been extensive. It occurs 
20 



306 DISEASES OF THE SKIN. 

also in xovy mild and very severe forms. The various terms 
used in the description of the forms of the disease, refer chiefly 
to its external features. 

Acne Artificialis. 

Various substances, cither applied topically to the skin or 
ingested, arc capable of producing acneiforra lesions. Among 
them may be named tar, which may prove such an irritant, 
whether employed externally or internally; and, far more fre- 
quently, the salts of iodine and bromine. Tar acne occurs both 
among workers in that substance and in those subjected to its 
action for the relief of other cutaneous disease. Pin head to 
pea sized, reddish-brown papules then form, at the apex of which 
is perceptible a minute blackish punctum, produced by the lodg- 
ment of a minute particle of the medicament in the orifice of a 
sebaceous follicle. Pustular and furuncular lesions are, how- 
ever, also produced ; and the same is true of bromic and iodic 
acne. In the latter, Adamkiewiez and others have demon- 
strated the presence of the drug in the contents of the pustular 
lesions. Chrysarobin and a number of other medicinal sub- 
stances are capable of exerting a like effect. 

Acne Atrophica and Acne Hypertrophica 

are terms employed to designate merely the lesion-relics of the 
disease. In the former, there is complete atrophy of the gland- 
tissue, indicated by a minute sunken pit in the site of the former 
orifice ; in the latter there is, in consequence of the periglandular 
exudation, a thickening of the tissues about the acini, and a 
projection from the surface, of persistent, pea-sized, and indu- 
rated masses. 

Acne Cachecticorum. 

These are the symptoms encountered in the subjects of struma, 
scorbutus, marasmus, chloro anaemia, and tuberculosis. The 
lesions more often develop on the trunk and extremities than 
over the face, and are papulo-pustules, pin-head to bean-sized, 
particularly indolent, and remarkable for their livid, purplish, 
lurid-red, or violaceous tint. The lesions are rarely indurated ; 
more often they arc seen as softish, pus- and blood-containing 
nodules, sluggish of career, and leaving minute cicatrices. Their 
features arc due entirely to the general cachectic condition of 
the subjects in whom they occur. 

Acne Indurata. 

This is a form of the disease less frequently observed than 
several others, but one which possesses certain distinct clinical 
features. Induration of the base of the acne papule may be 



ACNE. 307 

noted in many cases of tlie simple form of the malady; but in 
others, the glands seem generally to be distinguished as minute, 
very firm nodules, with no tendency whatever to suppuration. 
The surface of the skin is often without marked change in color 
or heat, the individual lesions indeed exhibiting at times an 
unnaturally whitish aspect. They are felt when the linger is 
passed over the surface, as dense, often conical projections, occa- 
sionally painful, and giving to the touch a sensation suggestive 
of the nutmeg-grater. Comedones may be often distinguished 
intermingled with the papules. The disease when well-marked, 
is apt to be extensive, occurring with characteristic expression 
among brunette, hairy males well advanced to the twenty-fifth 
year. It is often generalized over the forehead, cheeks, chin, 
and the back of the neck. 

Acne Papulosa. 

Here the lesions are of a papular type, ranging in size from a 
millet-seed to a coffee-bean, whitish or reddish in color, and 
varying in the amount of firm induration at the base. They 
are evidently due to hyperplasia of the periglandular tissue ; 
and are often commingled with pustules, papulo-pustules, and 
comedones. At the apex is often distinguished the blackish 
point characteristic of acne punctata ; or a minute, greasy, yel- 
lowish-white spot, which represents the non-pigmented extremity 
of an inspissated sebaceous plug. 

Acne Punctata. 

In this variety, the acne papule is formed about a comedo. 
When examined, its apex is discovered exhibiting the charac- 
teristic blackish punctual of that lesion. 

Acne Pustulosa. 

This is probably the most frequently observed of all the 
forms of the disease. The lesions, as usual, are apt to be com- 
mingled with papules, comedones and intermediate phases be- 
tween the functional and exudative involvements of the glands. 
The pustules may be large or small, containing merely a droplet 
of pure pus or, when a true furuneulosis ensues, a teaspoonful 
or more of the same fluid mingled with blood and serum. This 
may be speedily evacuated artificially or accidentally, be ab- 
sorbed, or remain for a long period of time in a species of cyst- 
like loculus, whence it can be finally expressed. In aggravated 
cases, two or more of these pustulo-furuncular depots may coa- 
lesce, forming nut-sized abscesses or, not rarely, become united 
by fistulous tracts, through which there is free communication 
of the fluid contents of two or more chambers. 



308 DISEASES OF THE SKIN. 

Acne Varioliformis 

is tlio term employed, by the French especially, to designate the 
lesions elsewhere described as molluscum epitheliale, the name 
being selected in consequence of the resemblance of the latter 
to the umbilicated pustules of variola. 

Acne Vulgaris 

is a term applied by several authors, to the composite eruption 
which is common in many clinical cases. Here the various 
lesions decribed above are associated, usually on the face and 
over the shoulders, each in several degrees Of development, often 
in conjunction with the scars left by prior eruptions. 

Etiology. — The causes of acne are in many cases exceedingly 
obscure, and are probably numerous. It is common to describe 
the puberal change in both sexes as a frequent cause of the dis- 
ease, but I am unwilling to regard a physiological crisis as a 
disease-factor. It can merely be asserted with safety that, with 
the growth of the hairs in both sexes at the period of puberty, 
there is an unusual activity of the sebum-producing function, 
and that this physiological, is then the more readily perverted 
to a pathological activity. Needless to say that tens of thou- 
sands escape acne, who survive puberty. The disease, however, 
is apt to appear first at this time of life; and, if not improperly 
treated, to disappear spontaneously when the full maturity of 
the body is attained. 

Inasmuch also as there is a close physiological connection be- 
tween the genital function and organs and the appendages of 
the skin, not only in man but in the lower animals (antlers of 
the stag, plumage of birds, etc.), it seems reasonable to conclude, 
a priori, that the disturbances of the former may lie reflected to 
the latter. Many facts support such reasoning. The effect of 
castration upon the male of many animals, is displayed in the 
appendages of the skin. In the same way, perverted sexual 
instincts and habits, or poorly-regulated sexual hygiene, and ute- 
rine disease (which is indeed often traceable to the causes just 
named) are often associated with an acne. To the same category 
belong the disturbances of the gastro-intestinal tract, including 
constipation, dyspepsia, mal-nutrition from various causes; and 
the struma, tuberculosis, etc., which are responsible for acne 
cachecticorum. The medicinal agents capable of producing 
artificial acne, either by ingestion or after external application, 
have been already named. 

I am, however, quite unwilling to admit that any one of these 
conditions can be recognized as efficient in the majority of pa- 
tients. Many cases of acne occur in perfectly healthy young 
people of both sexes. A careful record of the cases of the dis- 
ease treated by myself, preserved upon blank forms in which is 



ACNE. 309 

space for noting irregular performance of function in the other 
organs, exhibits no ailment common to the larger number. In 
these, therefore, it is proper to believe that the causes of the 
disease are entirely local, such as suffice merely to induce pri- 
marily alteration in the consistency, quantity, or chemical cha- 
racter of the sebaceous secretion, and either as a cause or result 
of this, an adenitis or periadenitis. 

Apart from the local causes to which reference has been made, 
one should not forget that the use of cosmetics; neglect of soap, 
or the use of the cheaper and irritating varieties; excessive 
shaving on the part of the young male; friction from hat-bands; 
"frizzes," "bangs," and dyed veils; too frequent fingering of 
the face (Wigglesworth); improper compression of the neck by 
tight collars; and along list of other topical irritants may prove 
the immediate cause of the disease. It is believed that blondes 
of both sexes are the more frequent sufferers. But this obser- 
vation may have been suggested by the circumstance that in the 
light complexions, the symptoms of the disease are more con- 
spicuous and disfiguring. It has certainly occurred to me that 
young brunettes, with thick skins and abundant growth of 
dark lanugo hairs, furnish the most obstinate cases. 

Pathology. — The microscopical appearances in acne are briefly 
those of an inflammatory process with exudation iuvolving the 
peri-glandular tissue of the sebaceous glands and hair follicles, 
and that about the common excretory duct. There is the usual 
vascular engorgement, the multiplication of protoplasm within 
and without the focus of the phlegmon, its metamorphosis into 
pus, often mingled with blood, the destruction by suppuration 
of the sebaceous gland, and often the preservation of the hair 
follicle, though the latter may also be involved in the destruc- 
tive process. According to Kaposi, there is no question but 
that the first stage of the disease is always an anomalous per- 
formance of secretion or excretion in the sebaceous gland. 
Visible cicatrices rarely result, unless the destruction of the ele- 
ments of the derma surpasses the original limits of the gland 
itself. Where suppuration does not occur, there is generally 
relief of tension by extrusion of the inspissated gland-contents 
and resorption of the plastic or fluid exudate in the periphery. 

Diagnosis. — The typical facies of acne vulgaris is readily re- 
cognized by the characteristic features already described. The 
reddish papules, pustules, comedones, and "lumps" in the skin 
of the face of a young subject; the evident involvement of the 
sebaceous glands; the history of a chronic affection destitute of 
itching and quite unscratched ; the occasional blood-crusts where 
lesions have been squeezed or incised, are all significant facts. 
The pustular syphilide of the face is not only to be differentiated 
by its share in the history of an infectious disease, but by the 
occurrence of characteristic crusts, its selection by preference, of 
the regions about the nose and mouth, its evolution in groups, 



310 DISEASES OF THE SKIN. 

and its aequelse in the form of superficial or deep ulcerations. 
Nevertheless, and this I hold to be a matter of prime import- 
ance as regards diagnosis, simple acne is exceedingly common 
in syphilitic subjects. The iodide of potassium is so largely 
administered for the relief of syphilis, and in so large a majority 
ol cases induces it. artificial acne, that the latter eruption often 
precedes tin- evolution <>!' the macular syphilide, and also with 
surprising frequency masks the latter by a commingling of 
lesions. Simple acne is common also among those who are 
veterans of syphilis. Acne does certainly at times resemhle 
variola, and I have seen several cases of the former actually 
mistaken for the latter. En most instances, the absence of fever 
and a brief delay will soon put an end to any doubt. 

Treatment — Acne is, I believe, an entirely remediable disease 
in every case properly managed from the first. Sears of ancient 
ravages of the affection are, it is true, indelible; but even these 
arc smoothed down in the progress of time, so that they become 
yearly less conspicuous and disfiguring. 

An' important consideration, at the outset of treatment of a 
patient affected with acne, relates to any local or internal medi- 
cation which has been previously employed. A very large pro- 
portion of all cases first claim the attention of the physician, 
after ingesting drugs or making topical applications which 
have decidedly aggravated the original trouble. With or with- 
out the advice of others, such patients have often been engaged 
lor months in swallowing the iodide of potassium, "red clover," 
and various nostrums calculated to "drive out" the disease; or 
in rubbing over the skin equally noxious "proprietary" sub- 
stances. In every such instance, the skilled physician should 
delay active treatment of the affection until the artificial acne 
has subsided, and the real condition of affairs can be clearly 
lecoguized. The patient should be directed to discontinue his 
or her former practice, to bathe the affected part in hot water 
at night, and after it is dried to apply any bland unguent. By 
these simple measures alone, many cases can be very greatly im- 
proved, and some completely relieved. Their simplicity should 
commend them to every reader of these pages. It is a good 
thing to know what not to do. 

In cases, whether previously treated or not, which have been 
purged of all suspicion of an artificial element, the local treat- 
ment is of prime importance, and in the perfection with which 
its details are observed, lies the key to success. What personal 
experience I have enjoyed, has produced the conviction that it 
is not the selection of several remedies of the many advocated 
for the relief of the disease, nor yet the successive substitution 
of one for another to meet any transitory indications in each 
case, which conduces to the happiest result. It is rather the use 
of a single method of recognized value, and its skilful adaptation 
to the changing conditions of the disease. 



ACNE. 311 

It is first necessary to evacuate the contents of all pustules, 
to express from the summits of papules where are the orifices of 
sebaceous ducts, all densely inspissated plugs of sebum, and to 
remove any comedoues which are present, by the aid of the 
comedone-extractor. For the purpose of opening the superficial 
and smaller purulent collections, the long needles used by the 
gynecologists are decidedly preferable; and for the larger and 
deeper furuncular lesions, a bistoury with a delicate and very 
narrow blade. A slight degree of skill will here repay the ope- 
rator. By gentle compression with the fingers, the whitish, 
yellowish, or blackish orifice of the duct may be detected, and 
at that point preciselj' the needle or bistoury should be thrust 
sufficiently deep to insure the removal of pent-up pathological 
accretions. Should blood flow in droplets from any of these 
slight wounds, it is rather to be encouraged than repressed, as 
relieving the hyperemia and engorgement of the small peri- 
glandular phlegmon. In one or several sittings, all lesions re- 
quiring such interference should be carefully attacked, and im- 
mediately after each, preferably while the pus and blood are 
still oozing, the part is to be bathed for several minutes in water 
as hot as can be borne with comfort. For many reasons, the hour 
before retiring is preferable, though not always practicable, in 
treating such cases, as then a bland ointment can be thoroughly 
applied and permitted to remain till the following morning. 

When one or several of such operations have completely re- 
lieved the skin of its engorgement and retained inflammatory 
products, a systematic use at night, of the spiritus saponis viridis 
with hot water, should be for a time practiced. Let it be noted 
here, however, that man}- cases which do not require the minor 
surgical operation described above, should be from the first 
treated in this manner. As the face is the most common seat 
of the disease, it may be, for the purpose of description, con- 
sidered as the affected part. 

The patient is seated befoie a basin of water, as hot as can be 
tolerated with comfort, and with a pad of white flannel or soft 
sponge, bathes the face till the skin is thoroughly moistened 
and softened by the heated water and steam. From ten minutes 
to half an hour may be well employed in this way, and it is a 
fertile source of the improvement which follows. Then, while 
the face is still wet, all pustules which have formed are emptied, 
and a sufficient quantity of the spirit of green soap is poured 
over the flannel or sponge, and the face thoroughly scrubbed 
with it. Finally the surface is cleansed with a surplus of the 
water, carefully dried, and anointed with a sulphur ointment. 

Some range may be observed in the employment of the two 
articles named. Thus the spirit may be diluted with cologne or 
rose-water, one half or more; or the soaps employed, in less im- 
perative cases, may be the best toilet, Sarg's glycerine or sul- 
phur soaps. The ointment, too, may be compounded by adding 



312 



DISEASES OF THE SKIN' 



half a drachm to two drachms (2.-8.) of the flowers of sulphur 
to the ounce (32.) of cold cream or vaseline. In the morning, 
the face is to be washed with cold water. 

This operation of Bt earning, soaping, and anointing, is to be 
continued, according to the severity of the case and the toler- 
ance of the patient, nightly, twice in the day, or on alternate 
nights, till the face is free from papules and other inflammatory 
lesions. It. at this time, is usually unsightly, reddened, slightly 
tumid, and often moderately furfuraceous, lint free from acnei- 
form lesions. To the patient, it feels tense, slightly painful, and 
as it made of leather. This accomplished, the spirit or other 
preparation of soap may he for the time discontinued, and the 
nightly bathing with hot water and subsequent anointing with 
the ointment regularly continued. The improvement which fol- 
lows is marked and speed} - ; and usually cpuite satisfactory to 
the patient. When this point is reached, a wider latitude of 
treatment is presented. 

Gradually the hot ablutions may -be withdrawn, and the use 
of lotions and ointments other than those containing sulphur, 
may he advised. The last-named substance, having the highest 
reputation in the disorders of the sebaceous glands, is a constit- 
uent of many of the lotions thus employed. 

Taylor 1 advises the following: — 



Sulphuris loti 


o'ij ; 




12 




Caraphorse spts. 


iSi'J ; 




12 




Sodse biborat. 


3U; 




8 




Glycerin. 


t'5vj ; 




2.-» 




Aq. fon tan. 


ad f.^iv ; 




130 


M. 


. Shake well and 


apply freely, leaving 


a thin 


film of powder over 


the face. 











Various combinations of sulphur with alcohol will be found 
useful. Thus Kaposi recommends a paste composed of: — 

R. Sulphur, prrecip. 3ijss ; 10i 

Spts. vin. rect. f§jss; 50 

Lavand. spts. . f3'J ss ; 1 0] 

Glycerin. n\,xx ; 1 1 M. 

Sig. To be spread over the face and retained during the night. Or, 



14 


Sulphur, ftor. 


5'.iss ; 


10 






Spts. sapon. virid. 


15v; 


20 






Lavand. tr. 


f§u ; 


60 






Peruv. bnls. 


n\,xx ; 


1 


3 




Camphor, spts. 


n\ xv ; 


1 






Bergamot. ol. 


"lv ; 




5 



Sig. To be applied over the face at night. 

Duhring recommends the following: — 



Sulphur, praccipit. 




3ij ; 


8 


Glycerin. 




f-i.i ; 


8 


Alcoholis 




m ; 


30 


Aq. calcis 




t'i.i ; 


30 


Aq. ros. 




Qtt ; 


60 


Sig. Shake the vial befor 


e using. 







' Amer. Clin. Lectures, vol. III. No. 10, N. Y. 1878. 



ACNE. 313 

The English hypochloride of sulphur, in ointments of the 
strength of those given above, and the sulphnret of potassium, 
half to one scrupfe (0.66-1.33) to the ounce (32.) of lotion or 
ointment, are effective, but objectionable on account of their 
odor. 

Various cosmetic ointments will be found useful in superseding 
those described above, as the case progresses. Among these 
may be named, the oxide of zinc, the subnitrate of bismuth, 
and freshly levigated calamine in the strength of from one half 
to one drachm (2.-4.) of one or more of these substances to the 
ounce (32.) of cold cream, to which, as required, the tincture of 
benzoin, glycerine, oil of roses, or bergamot, may be added in 
suitable proportion. 

The other substances employed topicaltyin acne, are certainly 
inferior to those named above. The bichloride of mercury is 
very generally employed in the strength of from one-eighth to 
one-half a grain (.008-033) to the ounce (32.) of lotion ; and 
the protiodide, biniodide and ammonio-chlorideof the metal are 
similarly applied in both lotions and unguents; the first two, in 
the strength of from five to ten grains (.33-66) to the ounce 
(32.); the last named, in the strength of from half a scruple to 
a scruple (.66-1.33). One should be careful not to make use of 
the mercurials at the same time with a compound of sulphur, 
lest a chemical combination occur by reason of which the sul- 
phuret of mercurj- is precipitated upon the skin and produces 
the appearance of the comedo. Heitzmann highly recommends 
the solution of Vlemincx, which I have never had the courage 
to employ in acne. 1 

Kaposi recommends also mercurial plaster applied on strips 
of linen, in obstinate cases, for which may be substituted 
iodated glycerine, five parts each of pure iodine and the iodide 
of potassium to ten of glycerine, applied with a brush twice 
daily till from six to twelve applications have been made. 

I believe that the use of caustics in acne, though recommended 
by several authors, should be discountenanced as quite needless. 
In extreme induration of the lesions, they may be rubbed with 
fine pumice stone till the desired effect is produced. 

The powders employed in the milder forms of the affection, 
are finely powdered sulphur, which may be freely dusted over 
the face; and those compounded, in various proportions, of 
starch, rice-flour, zinc-oxide, and the subcarbonate of bismuth. 

As regards the internal or constitutional treatment of acne, 
very often none is required, since many of the individuals who 
are subjects of the disease enjoy good health. Acne is, to a 

1 The formula is : — 

fy. Calcis gss ; 16 

Sulphur, sublim. §j ; 32 

Aq. fx; 32U 

Coque ad §vj (200.) deinde filtra. Sig. "Vlemincx's solution." 



814 DISEASES OF THE SKIX. 

satisfactory extent, remediable by local measures alone, and it 
is clear that they who employ a combination of constitutional 
and local treatment, if only the latter is skilfully managed, will 
have some difficulty in assigning to each its relative therapeutic 
value. The internal treatment of acne, therefore, may he prop- 
erly described as that which is indicated to the general practi- 
tioner of medicine, by the condition of his patient. Dyspepsia 
and constipation are, without doubt, to he corrected by medi- 
cinal measures, or even better by judicious attention to the diet 
and habits of the patient suffering from such disorders. The 
cathartics, saline and alterative, will often prove serviceable. I 
have rarely found it necessary to resort to arsenic, though it is 
highly recommended in acne papulosa, by both Duhring and 
Taylor. The internal employment of ergot in full doses for the 
relief of acne, as suggested by Ilardaway and Heitzmann, has, 
without question, been frequently followed by excellent re- 
sults. Cod liver oil, iron, the mineral acids, and the hitters 
will prove valuable in chlorosis and cachexia. The sulphide of 
calcium, in quarter of a grain (.016) doses, has proved of some 
benefit in obstinate cases. I have no question hut that the tem- 
perate gratification of the sexual instinct in a happy marriage, 
is conducive to good results; and such a change of condition, 
when anticipated, should generally he encouraged as favorable 
for the future of young adults. Uterine disease should receive 
proper treatment when such complication exists; and this, far 
less by topical applications, than by attention to the general 
health, as the patients of this class are more often chlorotic 
young women with menstrual derangements, leading sedentary 
lives, or overworked at the school-desk, the sewing-machine, or 
the shop-counter. The diet should be carefully regulated, and 
the rules of hygiene enforced. 

Acne Rosacea. 

Acne rosacea is a chronic disease of the skin, chiefly of the face, often devel- 
oped from, or associated with, the lesions of acne vulgaris, characterized by 
hyperaemic macula?, telangiectases, inflammatory papules, or vegetating 
masses, which may attain the size of a hen's egg. 

It is usual to describe three grades of this disorder, which is 
most often displayed upon the nose, though it may also affect 
the cheeks, lips, chin, and, rarely, the lateral regions of the neck. 

In the first grade, there is a more or less diffuse and uniform, 
pinkish or dusky redness, involving the extremity of the nose 
and its contiguous parts, which may extend from this point in 
a somewhat symmetrical figure over the cheeks and chin. The 
parts give rise to little or no subjective sensation. Under the 
finger, the color disappears upon pressure, the surface seems cool 
rather than hot, and the sebaceous glands are seen to be affected, 
as there is usually present either a seborrhcea oleosa or an accumu- 



ACNE ROSACEA. 315 

lation of yellowish-white, moderately inspissated sebum, in the 
patulous orifices of the gland duets. When the redness has 
existed for some time, minute bloodvessels can be seen ramify- 
ing over the erythematous surface. 

In the second grade, firm, purplish-red, painless, pin head to 
pea-sized nodules or papules rise from the erythematous surface, 
and either display minute superficial and tortuous bloodvessels in 
the integument by which they are covered, or project from a base 
about which such a telangiectasis has been very irregularly de- 
veloped. The lesions are apt to be intermingled with those of 
acne vulgaris. When fully developed, this stage of the disease, 
though generally not productive of marked subjective sensation, 
produces an exceedingly conspicuous deformity. 

In the third stage, which is the most, pronounced of the three, 
roundish, sessile, or pedunculated, lobulated, or pendulous, firm, 
elastic, pinkish-red, bluish, livid, or violaceous vegetations, tra- 
versed by finer or larger networks of bloodvessels, slowly de- 
velop about the affected part of the face, chiefly the nose. These 
may be single or multiple, and, in the latter case, isolated, or so 
closely united as to be scarcely distinguishable- from each other. 
The acneiform lesions seen in the second grade of the disease, 
may here also be apparent. In other cases, there is a uniform, 
symmetrical, and elongated hypertrophy of all the soft parts of 
the nose, which may thus attain colossal proportions. It is these 
consequences of acne rosacea to which the term rhinophyma 1 has 
been applied. 

The course of the disease is very slow, and in by far the 
largest numher does not produce the exaggerated types of the 
second and third grade. The lesions may persist indefinitely 
as indolent symptoms of the malady in any one of its stages, or, 
in the cases where there has been no new growth of vessels or 
tubercles, proceed to spontaneous involution. 

Etiology. — The first and second grades of acne rosacea are 
common in women either at puberty or near the period of the 
menopause, in those who are pregnant, or who suffer from 
utero ovarian disease, frequent miscarriages, sterility, irregular 
performance of the menstrual function, and chlorosis. It is, 
however, seen in males of early and late adult life. In both 
sexes, it may occur in ansemic and asthenic states. In both, also, 
its association with dyspepsia and the immoderate use of alco- 
holic drinks, beer, wines, and spirits, is a matter of common 
ohservation. According to Kaposi, the rosaceous nose of the 
wine drinker is bright red; of the beer drinker, cyanotic or 
violet; of the spirit drinker, smooth, supple, fatty, and dark 
blue. The new-growth of vessels and tubercles, with the rhino- 
phyma of the advanced grade of the disease, is much more 

1 For a full -discussion of this subject, consult a valuable paper by Hans 
Hebra, in the Viertelj. f. Derm. u. Syph., 1881, 4 Hft., p. 603, illustrated by cuts 
giving the gross and microscopical appearances of the disease. 



316 DISEASES OF THE SKIX. 

common in men than in women. Tn those whose faces are 
bronzed by exposure to the weather, the telangiectasia condition 
of tlic cheeks rather than of the nose, is of frequent occurrence. 
Veteran sailors and soldiers are thus commonly affected. Per- 
sona who have frozen the nose or cheeks on one or more occa- 
sions,are similarly liable to the telangiectasia development. Any 
externally or internally operating cause which tends to retard 
the capillary circulation in the superficial portion of the skin, is 
capable of inducing the result. I have seen it conspicuously 
displayed in the mulatto. 

Pathology. — Tn the first stage of acne rosacea, there is merely 
passive hyperemia. The circulation of blood in the superficial 
capillary plexus of minute vessels, is retarded. Persistence of 
this condition for long periods of time, results in paresis of the 
capillaries, with their consequent dilatation and hypertrophy, 
phenomena which characterize the second stage, the sebaceous 
gland disorder being a complication of the process. In the third 
stage, the nodules are found to be composed of new formed 
gelatinous elements, which become formed by organization. 
According to Biesiadecki, there is also dilatation and hyper- 
trophy of the sebaceous glands with dilatation, hypertrophy, 
and new-growth of the superficial vessels, and enlargement also 
of those trunks which ascend from the corium. 

Diagnosis. — Acne vulgaris is distinguished from acne rosacea 
by the absence of telangiectasis, and of the hypertrophic growths 
which characterize the developed lesions of the last-named dis- 
ease. The tubercular syphiloderm is recognizable by its ten- 
dency to ulceration and crusting, and by the entire absence of 
telangiectasis. When the tubercles of syphilis are limited to 
the extremity of the nose and are unusually small in consequence 
of the influence of treatment, they often degenerate into charac- 
teristic, split-pea sized, irregularly circular ulcerations, superfi- 
cial in seat and frequently isolated. They leave similarly shaped 
and sized, depressed cicatrices, at the tip and neighboring parts 
of the nose. As the process is much more rapid than in acne 
rosacea, these lesions, considered in connection with the absence 
of telangiectasis, furnish the most significant diagnostic symp- 
toms of the disorder, for they often occur late in the history of 
syphilis, in individuals of middle life, and in varying shades of 
a dull reddish color, circumstances particularly favorable for 
confusion regarding the identity of the two diseases. 

I have seen a single case of zoster from involvement of the 
superior maxillary branch of the trigeminus with diffused red- 
ness of one side of the nose and efflorescence of vesicles over its 
tip and ala, which certainly strongly resembled acne rosacea 
with pustular lesions. Here the painful character of the disor- 
der, its limitation to one side, its transitory career, and its 
vesicular lesions were sufficiently characteristic. 

Lupus vulgaris, like syphilis, when occurring upon the nose, 
is to be recognized by the tendency of its papulo-tubercular 



ACNE ROSACEA. 317 

lesions to ulceration and crusting, the absence of vascularity, 
and the frequent presence of characteristic cicatrices. Unlike 
syphilis and acne rosacea, however, the history of lupus vulgaris 
usually extends to early childhood. Lupus erythematosus is 
yet more readily different' ated, as it is not only unaccompanied 
by vascularity and ulceration, but is characterized by scaling 
and symmetrical diffusion over much larger areas, commonly 
extending from the bridge of the nose well on to the cheeks. 

Treatment. — The local treatment of the first grade of acne 
rosacea, is substantially that of acne vulgaris. Stimulating 
lotions of green soap, alcohol, bichloride of mercury, or sulphur 
in connection with ablutions by hot water, are of the highest 
value. In addition, the various ointments containing sulphur, 
the mercuric oxide and iodides, and the continuous applications 
of mercurial plaster, should be employed if necessary. 

When the diseased condition is that of the second grade, the 
indication is the destruction of the superficial capillaries, as 
well as the removal of the other lesions present. Hardaway, of 
St. Louis, destroys the vessels by single or multiple puncture of 
each with a fine cambric needle attached to the negative pole of 
a galvanic battery, with six to ten elements in the circuit. This 
is better than the knife which, in my hands, has repeatedly 
failed. Brushing the part cautiously with solutions of caustic 
potash, ten to thirty grains (.66-2.) to the ounce (32.) of 
water; and the local use of pure carbolic, chromic, and glacial 
acetic acids, acetum cantharidis (Taylor), iodide of sulphur, and 
the pernitrate of mercury are also available. Before any of these, 
however, is employed, an effort should be made to produce exfo- 
liation, by spreading over the part a plaster made of green soap. 
Kaposi highly recommends the solution of iodated glycerine 
employed by him in acne vulgaris (q. v.), which is painted over 
the part eight to twelve times daily for three or four successive 
days, and immediately covered with gutta percha paper. 

Multiple scarification of all new growths after the manner of 
attacking lupous nodules; erasion with the dermal curette; and 
surgical ablation of tumors by ligature and knife are also avail- 
able. After any destructive attack upon the diseased portions 
of the skin, the soothing lotions, fomentations, or ointments 
should be regularly applied. 

As far as there can be said to be any internal treatment of 
acne rosacea, it is that of acne vulgaris, but in neither disorder 
can such be confidently described as effective in the dispersion 
of the local lesions. The treatment is that of the patient rather 
than of his disease. Where alcohol has been in any degree pro- 
ductive of the local effects, the use of spirits, wines, and beer is 
to be interdicted; but as regards confirmed rosacea, this will 
prove to be of but little avail. I have seen the disease when 
resulting from brandy-drinking, persist after five years of total 
abstinence. 



318 DISEASES OF THE SKIN. 

Prognosis. — A favorable prognosis can be established only in 

3 where the disease is presented in its milder forms. In 

those complicated by marked telangiectasis and hypertrophy, 

the results of treatment are not in the highest degree encourag- 
ing. In spite of the most energetic procedures, the visa-tergo of 
passive hyperemia, involving often the deeper and unassailed 

bloodvessels, works its slow progress. For women, the future is 
in general more promising than in the ease of men. With the 
most unfavorable prognosis, however, it is to be remembered 
that, after all, the disease is one of deformity rather than of 
physical discomfort. 



Class III. —OF THE SWEAT GLANDS AND PERIGLANDULAR 
TISSUES. 

1. Anomalies of Secretion. 

The functional disorders of the sweat glands are characterized by a quantitative 
or qualitative change in the secretion of sweat. 

Hyperidrosis. 

By this term is designated an exaggerated effusion of sweat, 
the secretion accumulating in visible drops upon the surface of 
the skin. The condition may be physiological as the result of 
active exertion in a medium of high temperature; or it may 
become pathological in character, and in the latter case be either 
general or partial. 

General sweating to a pathological extent occurs chiefly in the 
obese, but also in those who are the subjects of constitutional 
disease (phthisis, the various febrile disorders, etc.). It is the 
fertile source of the various forms of intertrigo, sudamina, and 
miliaria. Local hyperidrosis is the exaggerated effusion of 
sweat limited to certain definite portions of the skin, as the 
palms, soles, dorsa of the hands and feet, the interdigital spaces, 
the genitals, the axillae, and temples. In such cases the secretion 
occurs moderately or greatly in excess, varying in this respect 
somewhat in different degrees of temperature and of rapidity of 
the circulation ; is occasionally but not commonly accompanied 
by fetor; and always occurs to a marked extent. It may invlove 
one or both sides of the body, being generally symmetrical at the 
extremities and asymmetrical upon portions of the face. 

Its typical expression may be studied in the hands which are 
continually moistened, clammy, or dripping with fluid within 
a brief time after the most careful drying of the parts. In the 
case of a woman, the instincts of whose sex prompt her to take 



HYPER1DR0SIS. 319 

such precautions, the dress is constantly protected from contact 
with the macerated palms by a handkerchief or similar article 
which is always in readiness. The disadvantages thus arising 
in individuals of both sexes who are engaged as tradespeople, 
artists, hand workers, etc., can readily be understood. In women 
of social position, no small complaint is made of the disagreeable 
result produced after wearing kid gloves for even a short time, 
the material of which is soon soiled by its complete saturation 
with the secretion from the skin. 

With and without this local excess, occurs the hyperidrosis of 
the feet, aggravated by the mechanical force of gravity and the 
need of constant covering. The stockings and the leather of the 
boots, shoes, or gaiters are saturated with the secretion, and be- 
come rapidly subject to chemical alteration. There is usually an 
offensive odor of the region, originating partly in the primary 
fetor of the secretions themselves, and partly in the subsequent 
chemical decomposition of the latter, rapidly progressing under the 
influence of the soiled and often stinking investments of the feet. 

The integument, constantly macerated, may become both pain- 
ful and tender; very rarely there is vesiculation or exfoliation 
of patches of sodden epidermis. When the genitals are involved, 
especially in the male, erythema and intertrigo are the frequent 
results. 

The causes of the disease are obscure, authors being divided 
as to the relative etiological influence of the nervous, muscular, 
and the vascular systems. The disease is encountered in individ- 
uals of both sexes, and in all ages and degrees of general health, 
as also in those who are and those who are not, careful as to 
cleanliness. I am inclined to believe, as a result of observation, 
that the facial symmetrical hyperidroses associated with migraine, 
neuralgias, hemicrania, etc., are etiologically and pathologically 
distinct from the similar symmetrical affections of the hands and 
feet. The latter certainly do occur with conspicuous frequency 
in young adult women who are the subjects of chloro-angemia, 
some form of dysmenorrhcea, or cardiac trouble. In one young 
female under my own observation, I discovered an habitual pulse 
of fifty-five to the minute without dicrotism, the patient being 
in other respects well. In her usual household avocations, she 
was generally provided with a towel for the absorption of sweat 
from the hands. The disorder usually lasts for years, but may 
spontaneously disappear. 

Hyperidrosis is locally treated by the diligent application of 
the dusting powders, lycopodium, zinc oxide, salicylic acid, bis- 
muth, or magnesia, the starch-containing compounds being here 
subject to the disadvantage, when commingled with the sweat, 
of forming minute rolls or cakes which irritate the skin. In the 
interval of applying these or alternately with such applications, 
astringent lotions or baths may be used, consisting of solutions 
in alcohol or water, of tannin, alum, corrosive sublimate, per- 



320 DISEASES OF THE SKIN. 

manga n ate of potassium, sulphate of zinc, or the preparations of 
sea-salt now found in the American market. 

For byperidrosis of the feet, the treatment by the method of 
Hebra has, deservedly, the highest repute. It consists in neatly 
and completely enveloping the entire foot and toes separately, 
after thorough washing and drying, in strips of cotton cloth 
over which is spread to the thickness of the blade of a common 
knife, the unguentum diachyli albi already described. This 
hitter, it will be remembered, is made by boiling one part of the 
best litharge with about four parts of pure olive oil, to which 
a little water is added while the materials are stirred together 
over a slow fire. (For Duhring's modification of this ointment 
see page 132.) The parts are well bandaged, and the patient 
either remains subsequently at rest or pursues his avocation, 
wearing over the feet, shoes and stockings which have not been 
previously used. In twenty-four hours, the feet are redressed 
without washing, after dry rubbing with charpie and a dusting 
powder. This is repeated daily for ten to twenty days, after 
which a dusting powder may be substituted for the local dress- 
ing. A parchment-like desquamation of the epidermis in thick, 
yellowish-brown lamellae occurs, beneath which an epidermis 
is formed, new and at first tender, hut apparently normal. When 
the latter has lost its tenderness, the feet are for the first time 
washed with water. In case of failure, the routine of the treat- 
ment is, as often as necessary, again carried out. It is scarcely 
necessary to add that no ill effects are known to have resulted 
from the therapeutic measures adopted for checking a local 
byperidrosis. 

Internally, the use of chalybeates, quinine, strychnine, bella- 
donna, ergot, and the vegetable and mineral tonics, may be 
indicated, and, in the mild and fugitive forms of the disorder, 
possibly prove of service. In the confirmed and symmetrical 
varieties of the disease, they will scarcely do more than benefit 
the general condition of the patient. 

Bromidrosis. 

In this variation from a normal standard of the sweat func- 
tion, the secretion is either effused in such a state that it can be 
immediately perceived to possess an unusual odor, or, as Hebra 
taught was the case with the majority of patients, rapidly 
changed to that condition. It may be, and often is, associated 
with hyperidrosis, or may occur quite independently of the 
latter, and like the latter also be either general or partial. The 
odor may be either agreeable or disagreeable, having been in 
various cases compared to that of several flowers and fruits, as 
well as to that of various stench-emitting animals. In this respect 
the sweat presents a striking analogy to the urine, with which 
it sustains a close and well recognized physiological relation. 



ANIDROSIS. 321 

General bromidrosis may be physiological, as in the case of 
individuals of the African race, or in those of dark skins who 
are profusely sweating during labor or in exalted temperatures. 
General pathological bromidrosis is rare. The odors emanating 
from the person in ulcerating syphilodermata, smallpox, and 
other general disorders, may, in certain cases, be associated with 
the sweat secretion, but in others doubtless are connected with 
the decomposition of pathological products of the inflammatory 
process. 

The local varieties of bromidrosis affect the regions in which 
the sweat is oftenest secreted in excess, and its immediate evap- 
oration prevented, as in the axillge, groins, feet, ano-genital, in- 
ter- and infra-mammary regions. In a qualitative sense, every 
degree of odorousness is noted, from that which is merely slightly 
agreeable or offensive, to the most intolerable stench. When 
complicated by a seborrhcea in situations where the parts are not 
only warm, moist, and covered by clothing, but also subjected to 
friction and long uncleaused, the most intolerable and nauseous 
fetor is perceived. 

Treatment. — The treatment of bromidrosis is in general that 
of hyperidrosis already described. Thin 1 has successfully em- 
ployed stockings and cork soles dried thoroughly, after satura- 
tion for hours in a jar containing a solution of boracic acid. 
The efficacy of this, he ascribes to the fact that the odor is the 
result of the development in the secretions of the bacterium 
foetidum. An ointment is also employed by him for similar 
purposes, produced by making a solution of the acid in glyce- 
rine, and incorporating it with a fatty basis of white wax and 
almond oil, making thus a "glycerated cream of boric acid." 
Armingaud, of the French Academy, has reported excellent 
results following the subcutaneous injection of three grains (.20) 
of the nitrate of pilocarpine, eight of which operations were suc- 
cessful in reducing the abnormal sweating and fetor. Clement 
Hawkins 2 finely triturates fifteen grains (1.) of the red oxide of 
lead, and to this adds gradually one ounce (32.) of Goulard's 
extract. This is used as a lotion following a nightly foot-bath 
containing an ounce (32.) of alum. 

Anidrosis. 

Diminution in the quantity of sweat excreted or its complete 
suppression, whether general or local, is a symptom of several 
disorders, but as a separate cutaneous affection has no existence. 
It is sufficiently common in many cutaneous diseases as, for ex- 
ample, ichthyosis, psoriasis, and some forms of eczema. But in 
these, the symptomatic character of the anomaly is illustrated 
by the well-known fact that when the skin is relieved of these 

' Practitioner, Dec. 1881, p. 401. 
2 Brit. Med. Journ., May 7, 1881. 
21 



322 DISEASES OF THE SKIN. 

cutaneous troubles, the function of sweat secretion is restored. 
Similarly, in neuralgias and certain forms of paralysis, a circum- 
scribed and temporary anidrosis may be the local expression of the 
nervous disturbance, precisely as in the case of the asymmetrical 
hyperidroses. Lastly, there arc individuals exhibiting the idio- 
syncrasy of sweating either not at all or quite imperceptibly in 
elevated temperatures, phenomena which I should prefer to as- 
scribeto peculiarities in the. equilibrium of the heat-exchanging 
forces, than to congenital deficiency of the sweat glands. 

Treatment — The measures capable of stimulating the sweat 
secretion are; the ingestion of water in quantity by the mouth, 
the external application of heat in a dry or moist atmosphere, 
and the use of jaborandi or pilocarpine by the mouth or hypo- 
dermic injection. In the anidrosis accompanying cutaneous dis- 
ease, the indication is always primarily for the relief of the 
latter. 

Chromidrosis. 

Cases are on record in which effused sweat has been variously 
colored in shades of red, yellow, green, black, and blue. In 
these there has been usually a copious secretion of fluid. Au- 
thors have variously attributed the color to the presence of com- 
pounds of phosphorus, iron, cyanogen, indican, Prussian blue, 
and even to parasitic vegetations upon the surface. Women, 
much more than men, are apt for the free deposit of pigment 
upon the skin, and, in view of the admitted rarity of chromi- 
drosis, the suspicion arises that in some of the cases reported, 
there was free pigmentation of the surface by which the fluid 
exuded was immediately stained or colored. Duhriug reports 
a single case of red sweating in a vigorous male patient. Usually, 
however, the phenomena occur in persons who betray some evi- 
dence of impairment of other organs than the skin, or who are 
debilitated in general health, thus furnishing an indication for 
their treatment. 

Babesiu, 1 of Pesth, reports some interesting cases of this dis- 
order, which appear to have been produced by the presence of 
bacteria. A woman, twenty-six years of age, presented pale- 
red sweat in the right, axilla, where the skin and hairs were also 
slightly reddened. From time to time the perspiration became 
blood-red in color, associated with hysterical and nervous dis- 
turbances. A sister, who slept with her, was affected in a simi- 
lar manner, the perspiration in the right axilla becoming red. 
A third case presented itself in a young, healthy man, who 
complained of occasional blood-red sweat; and a fourth, in a 
young woman. In all, the symptom was associated with trouble- 
some itching. Microscopical investigation yielded in all the 

1 Lancet, 1882. 



CHROMIDROSIS. 323 

cases a similar result. The hairs of the axilla? were thin, pale- 
red, brittle; and surrounded with a colloid-looking;, rusty, or 
bright red sheath, in places, of considerable thickness, and having 
a rough surface. It consisted of red masses, presenting a radiat- 
ing striation, more or less confluent, apparently proceeding from 
fibres of the cortex of the hair, or from some broken part of its 
surface. The radiating striation was found to be due to the 
aggregation of round or ovoid bacteria, scarcely a micro-milli- 
metre in diameter, which were united in zoogloea masses by a 
reddish, intermediate substance. Modular swellings on the hair 
were produced by the infiltration of the organism between the 
separated fibrils. The roots of the hair were free from bacteria. 
The red tint of the sweat was found to depend upon numerous 
roundish masses of zoogloea. 

T. C. Fox 1 also has reported two cases in which a deep bluish- 
black pigment was exuded upon the skin of the circum-orbital 
region. The amorphous granules were found insoluble in al- 
most all hot or cold reagents, but displayed a deep blue color 
when moistened with glycerine, and a purplish hue when dis- 
solved in hot sulphuric acid. 

The hypothesis, that certain cases described as chromidrosis 
are really instances of mechanical washing of pigment to the 
surface in the profuse sweating of the debilitated, is strength- 
ened by the phenomena of simultaneous hair coloration. Thus 
Prentiss 2 reports the case of a young woman affected with acute 
cystitis and purulent urine, whose hair, under the influence of 
profuse sweating induced by the action of pilocarpine, changed 
speedily from a light blond to a nearly jet black hue. At the 
meeting of the American Dermatological Association, in 1881, 
I exhibited hairs of a middle-aged man which had changed in a 
night from a grayish-white to a greenish and yellowish-brown 
hue ; and, in commenting upon these, Dr. White, of Boston, 
stated that he had observed several similar cases of hair color- 
ation as the result of profuse sweats. 



Abnormal conditions of excreted sweat, other than those de- 
scribed above, have been from time to time noted by various 
observers. Some of these are supported by a reasonable basis 
of fact, others not. Hasmatidrosis, for example, the so-called 
sweating of blood, is, in general, a pathological exudation of 
that fluid upon the free surface of the skin without the occur- 
rence of traumatism, and quite independent of the action of the 
sweat glands, in patients affected with haemophilia. Under these 
circumstances, it is not surprising to find that at times the sweat 
secretion is commingled with blood, which, by diapedesis ; enters 

1 Med. Press and Circular. Jan. 1, 1881. 

2 Phil. Med. Times, July 2, 1881, p. 609. 



324 DISEASES OF THE SKIN". 

the sudoriparous gland from tlie delicate vascular plexus which 
surrounds it, as Parrot 1 and others have shown. 

In the effort to eliminate certain substances, accidentally or 
otherwise introduced into the system, the sweat may possibly 
become charged with iodine, turpentine, tar, arsenic, phosphorus, 
ami other articles. After the ingestion of the last-named sub- 
stance, the secretion is said to have occasionally become lumi- 
nous. Douhtless several of the eruptions described in the chap- 
ter on dermatitis medicamentosa are due to a similar eliminative 
effort, especially those accompanied by excessive sweating and 
the production of vesicnlation. 

With equal reason it may he inferred that the sweat is at 
times charged with excrementitious and other products of the 
human body; as, for example, the principles of the bile. During 
the late civil war, I observed several patients affected with yel- 
low fever whose skins exhibited the characteristic hue of that 
disease, and whose sweat was similarly colored. The so-called 
" galactidrosis," from supposed metastasis of milk, does not 
occur. Cases thus described have been instances of pathological 
sweat in the puerperal state. 

The fact of the occurrence of urinary sweat, uridrosis, is, how- 
ever, based upon positive proof, that, viz., of the discovery of 
urea and urinary salts deposited upon the skin surface after 
evaporation of the exuded fluid. Such symptoms have usually 
occurred either as the result of grave constitutional affections, 
such as cholera; or of organic renal disease, accompanied by 
anaemia; or of the ingestion of jaborandi. In a few cases, the 
symptoms have been presented in individuals who were appa- 
rently in good health. The salts of the urine appeared upon the 
skins of these patients, in the form of minute lamellae, or a fine 
powder of whitish color and crystalline aspect. In some cases 
reported, the symptoms have been noted to precede by a few 
days a fatal issue. 

Uridrosis, then, cannot be properly designated as a disease of 
the skin. 

Sudamina. 

Deriv. Lat. sudor, sweat. 
Sudamina is a disease characterized by the occurrence of discrete, superficially- 
seated, millet-seed sized, translucent vesicles resembling seed-pearls 

The lesions in sudamina are very thickly agglomerated, but 
discrete, transitory and translucent, pin-point sized vesicles, re- 
sembling minute sweat drops, or seed-pearls, upon the surface of 
the skin, often requiring the touch to define their real character. 
They are usually limited to certain regions of the body, as the 
trunk, and here more generally upon the face and sides of the 

1 Etude sur la sueur de sang, etc., Gaz. de Med. et de Chir., 1839, t. vi. p. 
633 et seq. 



MILIARIA. 325 

belly and the iliac regions, though they may occur upon any 
part. Their course is rapid both in evolution and involution, 
and their sequelae are exceedingly delicate desquamative flakes, 
the thin roof-wall which originally covered the sweat-drops lifted 
from the superficial stratum of the horny layer of the epidermis. 
They contain each a droplet of sweat, which is removed by evapo- 
ration. The disease is a mere incident of profuse sweating, in 
debilitated conditions of the system, accompanied by the febrile 
process, as in enteric and other fevers, phthisis, and inflammatory 
rheumatism. 

The lesions are the result of the accumulation of sweat between 
the most superficial layers of the stratum corneum, in high tem- 
peratures of the body or of the medium by which it is sur- 
rounded, and usually in states of adynamia. They may hence 
occur at all ages of both sexes. 

The disease is not inflammatory, nor yet can it be described 
as purely functional in character. It occupies a middle ground 
between the two, sustaining thus the relation which is observed 
in several diseases, assignable with difficulty to the exact limits 
of artificial classes. 

The treatment is that of the diseased condition in which the 
lesions are produced. 

2. Exudative. 

Miliaria. 

Deriv. Lat. milium, a millet-seed. 
Miliaria is an acute exudative affection of the sweat glands and periglandular 
tissues, characterized by the occurrence of numerous, discrete, whitish or 
reddish, millet-seed sized vesicles, papules, or vesico-papules, productive of 
sensations of heat and pricking, and often accompanied by hyperidrosis. 

Symptomatology. — Under this designation, it is intended to 
class all those lesions which occur as inflammatory symptoms in 
connection with profuse sweating. The terms lichen tropicus 
(or prickly heat), miliaria alba, miliaria rubra, miliaria papu- 
losa, miliaria vesiculosa, and miliaria crystallina, are merely 
descriptive of certain shifting characters of the eruption ; and, it 
must be confessed, have engendered some confusion with regard 
to its features. 

The disease is characterized by the occurrence of pin-point to 
pin-head sized vesicles, papules, vesico-papules, or the two as 
coincident and commingled lesions. They are exceedingly nu- 
merous, and may in severe cases cover almost the entire so-called 
non-hairy surface of the body, though they may be much more 
limited in their diffusion. They are usually acuminate and 
discrete, though often very thickly set together. They are rapid 
of occurrence, but may, in consequence of persistence of the cause, 



326 DISEASES OF THE SK1X. 

be Bomewhat Blow in disappearing, or lie succeeded by crops of 
new lesions. In tbe white form (miliaria alba) opalescent 
ilea alone exist, and constitute thus an exaggerated sudamina, 
decidedly the rarer phenomenon. Much more frequently there 
is a decided and vivid redness, either as a halo about the base 
of the minute vesicles or of the pure papules, or of the papules 
at whose summit a minute vesicle Las formed (miliaria rubra). 

The eruption is seen upon the trunk, extremities, and lace, 
and is almost invariably accompanied by hyperidrosis, though 
the latter may be absent in high temperatures. The marked 
tingling, pricking, and burning sensations by which it is accom- 
panied, are often in the highest degree distressing, and may so- 
licit rubbing of the affected part, though the scratching elicited 
by severe pruritus is not common. Minute crusts may form 
after vesicular rupture. The attack may be mild or quite severe; 
and last for a few days, or for as many weeks or months, as the 
result of continuous aggravation, or of the production of new 
crops of lesions after each recurrence of the cause. It is not 
rarely complicated in obese individuals, by all varieties of inter- 
trigo and eczema. 

Etiology. — The disease is induced by stimulation of the sweat 
glands under the influence of heat; and is, therefore, most fre- 
quently noted iu elevated temperatures of the atmosphere. It is 
aggravated by all internal and external irritants, including alco- 
holic beverages, opiates, flannel, or other coarse under-garments, 
and friction of every sort. Excessive exertion on the one hand, 
and excessive prostration on the other, are equally effective. It 
Las seemed to me, after a somewhat extended observation of the 
white races in Africa, that the disease is more common in those 
subjected to rapid and intense fluctuation in the temperature of 
the atmosphere, than in those long accustomed to a relatively 
hot climate. It is thus exceedingly common in the northern 
parts of our own country, where the absence of the regulating 
gulf stream ushers the inhabitants suddenly from the rigors of 
a severe winter to the prostrating heats of summer. It attacks 
alike individuals of both sexes and all ages, being often particu- 
larly severe in the obese, and in infants, whose delicate skins, 
no less than their bowels, resent sudden and severe thermometrie 
changes. It moreover affects equally those who are vigorous 
and the debilitated. 

Pathology. — Miliaria is occasioned by afflux of the blood in 
excess of that which is physiological, to the periglandular vas- 
cular plexus of the sweat follicle. In various degrees, from 
transitory hyperemia to active exudation with the formation 
of vesicles, tli is pathological afflux may be exhibited in the symp- 
toms of the disease. When, however, as is usually the case, the 
exciting cause of the trouble is withdrawn before the production 
of excessive effects, the disorder does not advance to the grade 
of pustulation and active discLarge from the surface. Continu- 



MILIARIA. 327 

ation or repetition of the cause (as in long exposure to very 
high temperatures, or aggravation of the surface affected with 
miliaria by friction or macerative action) is sufficient to beget a 
troublesome eczema of any type, a fact I have frequently observed 
in the tropics. It is by no means certain that the congestive 
effect of the heat and sweating, is limited to the region of the 
sudoriparous duct, at even an earlier period than this. In the 
heated and sensitive skin of the patient suffering from the dis- 
order, it seems reasonable to conclude that other portions of the 
epidermis and corium would exhibit a sympathetic hy perse mia 
or exudation, and such, certainly, is suggested to the careful 
observer by the clinical features of a well-marked ctise. 

Diagnosis. — The diagnosis of miliaria rests chiefly upon: the 
recognition of the cause of the disease, viz., exposure to high 
temperatures of the atmosphere ; the pricking and tingling 
rather than the severe itching sensations which it occasions ; 
the rapidity of its course; and the usually distinct isolation of 
its lesions, however closely they may be set together. From the 
very superficial vesicles of sudamina, those of miliaria can be 
recognized at once by their evident involvement of portions of 
the skin deeper than the horny layer. From papular and vesi- 
cular eczema, the similar forms of miliaria may be distinguished 
by consideration of the features described above. Should the 
case be doubtful, in consequence of a commingling of the symp- 
toms of the two disorders, no difficulty need arise. That the 
one may merge into the other by insensible gradations, cannot 
be denied. Heat and sweating are the fertile sources of eczema 
as well as of miliaria, and it would not be unphilosophical to 
conclude that the latter is simply one of the many approaches 
to the former by the avenue of the sweat glands. Certain it is, 
that every miliaria can be artificially transformed into an eczema. 

Dermatitis medicamentosa may be readily confounded with 
miliaria, and is indeed at times clinically merged with that dis- 
ease. There are few practitioners who have not seen patients 
affected with "prickly heat" in summer, their symptoms inten- 
sified by the drugs they have swallowed in the hope of securing 
relief. In tiie latter event, the eruption is often widely gene- 
ralized and quite symmetrical, accompanied by unusual degrees 
of papulation, vesiculation, erythema, and intensely annoying 
subjective sensations, without recent undue exposure to heat. 
Sometimes a history of ingesta can be obtained. 

Duhring calls attention to the difficulty of recognizing the 
disease when its vesicular lesions complicate mild forms of scar- 
latina ; and the same might be said of papular urticaria, which 
in a teething, fretful child, bathed in perspiration, would be 
indeed almost indistinguishable from it. The recognition in 
any such case of the exact source of the cutaneous hypersemia 
and mild exudation, papular or vesicular, would involve merely 
a question of etiology. 



328 DISEASES OF THE SKIN. 

Treatment. — Tin* local treatment of miliaria is, in brief, that 
of the corresponding Btage of eczema. Unguents are to l>e 
scrupulously avoided, a8 the skin cannot tolerate them, and the 
Bame may be said of plasters and very cold baths. Baths or 
lotions, tepid, warm, or moderately cool, as the feelings of the 
patient may decide to he most grateful, medicated with alkalies, 
bran, gelatine, or starch, will be found useful. After each, the 
skin is to be dried, not by rubbing, but by gently pressing dry 
cloths over the surface, and is then to he thoroughly protected 
by a free use of one of the dusting powders. When large tracts 
of the skin are involved and general baths have, been ordered, a 
package of "corn-starch farina" will often he found sufficiently 
well suited for Buch topical employment. 

Lotions may also he employed, composed of lead, or lead and 
opium, or alcoholic and ethereal solutions containing camphor 
and glycerine in the proportions given when considering the 
subject of acute eczema. I have also found modifications of the 
oleated lime-water serviceable in severe cases with eczematous 
features; as, for example — 



$. 01. lini 


flu; 


65 


Paraffin. 1 

Sapon. Castil. f 


aa §ij ; 


65 


01. bergamii 


q. s ; 


q. s. 


Aq. calcis 


ad Oj ; 


500 


Sig For external use. 







This makes a demulcent creamy solution which often proves 
exceedingly grateful to the skin; and to it may he added the 
zinc oxide or dilute hydrocyanic acid, as may he required. 

After all, however, the general treatment of the patient is a 
matter of importance. The cause must he removed if possible. 
Withdrawal from the light, heat, and lahorof the day; unstim- 
ulating food and drink, nnirritating apparel, and rest, are of the 
greatest importance. The saline and acidulated heverages are 
usually acceptable to the palate, and useful if not drunk too 
cold. The chief value of Apollinaris water, lemonade, Vich}-, 
ami Tvissino-en, lies not in their action as medicaments, but as 
supplying the water demanded by the cutaneous loss through 
evaporation. 

Prognosis. — The disorder may he trivial and severe, and last 
hut for a few hours or as many months. It is usually relieved 
without difficulty, and often by domestic measures alone. It 
is most annoying and severe when complicated by the exudative 
process in other parts of the skin than the sweat-ducts and their 
immediate vicinage. 

Miliary Fever, 

Or the mette miliaire of the French, is an epidemic disorder of 
grave character, accompanied by sweating and a cutaneous ex- 



MILIARIA. 329 

anthem. Pineau, 1 one of the latest writers on the subject, gives 
a description of the disease as it occurred lately in epidemic form 
in the island of Oleron, where, of one thousand patients affected, 
between one hundred and fifty and two hundred perished. 
The eruption appeared in the form of hypersemic macula?, disap- 
pearing under pressure, after which there formed rapidly myriads 
of reddish or whitish projections, grouped, unequally sized, and 
acuminate papules, rising from a whitish and macerated surface. 
Among these were interspersed lesions of sudamina. The re- 
gion of the face was not spared, and the conjunctivae were ex- 
ceptionally affected. In the course of from two to four days, 
pin-head to bean-sized, varioliform but non-umbilicated pustules 
formed in the site of some of the papules, the contents of which 
disappeared by resorption, the final lesions presented being large, 
flat, reddish papules, the skin, of the face particularly, becoming 
generally reddened and swollen. In the course of from ten to 
twelve days, general desquamation ensued with large palmar and 
plantar losses. Relapses occurred in some cases with general 
redness of the surface, or with crops of reddish plaques, or yet 
again with the occurrence of furuncles. The sensations were 
tliose of myriads of needles thrust into the skin. The exanthem 
was accompanied in some cases by fever, and in others not. In 
fatal cases death resulted from exhaustion. 

Bysidrosis. 

Under the names dysidrosis and cheiro-pompholyx, Tilbury 
Fox and Hutchinson, of London, respectively, have described 
cases in which deeply -imbedded, pin-head sized, acuminate, pri- 
marily translucent vesicles, occur upon the palmar and inter- 
digital surfaces. Both in consequence of coalescence and in- 
crease in size, bullae may subsequently form, an inch or more in 
height, filled with an alkaline or slightly acid fluid supposed 
to be sweat. Partial absorption occurs if the lesions be undis- 
turbed, after which desquamation ensues from a reddened, non- 
discharging surface. The cuticle about the lesions may be 
sodden and macerated or reddened; it is usually painful and 
swollen. There is often produced a sensation of pricking, burn- 
ing, or itching. The eruption is most commonly discovered 
upon the hands and, less frequently, the feet; though other 
portions of the body may be involved. 

No little controversy has arisen respecting the exact nature 
of this disease, Fox and Crocker, on the one hand, 2 claiming a 
sudoriparous origin for the malady, while Robiuson, 3 of JSTew 
York, concludes, from a careful study of a single case, that 

1 Arch. Geuer. de Med., Jan. 1882, p. 25. 

2 The Histology of Dysidrosis, London, 1878, from Trans of the Path. Soc. 
of London, vol. xxix., 1878. 

3 Pompholyx, Arch, of Derm., vol. iii., No. 4, lb77, p. 289. 



330 DISEASES OF THE SKIN. 

pything points against its being an affection of the sweat 
glands." 

Mj <>\vn conclusions are based upon a careful study of some 
interesting cases under my personal observation. It is probable 
that in some of them the disease originated in the sweat follicles, 
as the appearance and behavior of the vesicles certainly indi- 
cated. In others, the eezematous features were more pronounced; 
and the latter, in two instances, seemed to have been exeited by 
the former. If the remarks heretofore made relative to the 
absence of a strictly defined dividing line between disorders of 
the Bweat glands and eczema be based upon fact, here surely 
such an explanation of these differences may be urged. 

But a point of special interest in this connection is, it seems 
to me, the occurrence of the affection chiefty among the cachec- 
tic. Fox says " I never knew any patient who had this disease 
. . . well." lie describes a condition of well-marked cachexia in 
all bis cases. Robinson's patient was sickly for years, had twice 
suffered from fracture of the femur, had lost three of six children, 
and was "-depressed." The severest lesions exhibited by my pa- 
tients, were those of a woman who had chronic enlargement of 
the spleen; and of a man who was profoundly cachectic, suffered 
from night-sweats, had a sallow hue of the skin, and subse- 
quently died paraplegic. 



Class IV.— OF THE HAIRS. HAIR-FOLLICLES, AND PERI- 
FOLLICULAR TISSUES. 

1. Atrophic. 

Alopecia. 

Deriv. Gr. x\virr,%, a fox. 

Alopecia is a physiological or pathological, symmetrical or asymmetrical, partial 

or complete, deficiency of hair. 

Congenital Alopecia. 

In rare cases, there is a partial or complete absence of hairs at 
birth, in consequence of an arrested development of the pilary 
system. Generally, however, these appendages of the skin n re 
merely of tardy appearance, their eruption being extraordinarily 
delayed, as in cases of retarded dentition. 

Senile Alopecia. 

The baldness of old age, whether occurring upon the vertex 
so as to produce a tonsure like that of the priest, or whether 
limited to the frontal region, or so extensive as to involve nearly 



ALOPECIA. 331 

the entire calvarium, leaving; a fringe of hairs at the occiput 
and temples merely, is always remarkable for its symmetry. 
There is hence a certain degree of dignity added to the appear- 
ance of the head, which an asymmetrical loss of hair could not 
produce. It may occur at varying ages of advanced life, and is 
quite frequently traceable to an early seborrhcea sicca. It is 
much more common in men than in women; and this, I believe, 
partly, because of the difference in the manner of covering the 
head in the two sexes, women usually wearing an exceedingly 
light covering for the head, while men encase the latter with 
tight fitting caps or hats which interfere with proper aeration 
of the scalp. Individuals of the male sex also, in consequence 
of their usually wearing the hair short, bestow far less time upon 
the care and dressing of it. In uncivilized races, where these 
differences are less marked, and where males pay great attention 
to the ornamentation of the scalp, senile baldness is of less fre- 
quent occurrence. 

The bald surface is, as a rule, smooth and shining; it is occa- 
sionally the seat of a seborrhcea oleosa. The hair follicles, with 
their accessory sebaceous glands, and occasionally the skin itself, 
are often in a state of atrophy, though there may be dilatation 
of the sebaceous glands. There is commonly some blanching of 
the hairs which are gradually shed, as also of those which re- 
main, though this is not constant. These conditions are much 
less frequent upon the surface covered by the beard, and pubic 
and axillary hairs. 

Premature Alopecia, 
Or premature calvities, is that form of acquired baldness which 
occurs in individuals who have not attained advanced years. 
It may be either idiopathic or symptomatic. 

The idiopathic variety does not originate in the diseases of the 
scalp or of the general economy which are recognized as effective 
in the production of other forms of baldness. It is, as with 
senile alopecia, more common in men than in women, and is, in 
the former sex, decidedly prevalent among those leading seden- 
tary lives. The loss of hair may be produced either rapidly, or, 
more commonly, slowly; and at any period after the puberal 
epoch. The pilary growth may gradually and evenly recede 
from the forehead, or, what is more frequent, recede on either 
side of the median line, leaving a more vigorous crop extending 
centrally toward the root of the nose, or produce the effect of 
the tonsure described above. It is always symmetrical, and 
usually remediless, partial calvities being the permanent result 
of the process. In many families, there is a predisposition to 
this premature loss of hair, which may be recognized in the 
males of succeeding generations. 

Symptomatic premature alopecia is the frequent result of a 
series of local and general disorders which vary in their gravity. 



332 D1SKASES OF THE SKIN. 

Sudden and gradual symmetrical thinning: of the hairs or com- 
plete baldness, is sufficiently common as the result of seborrhoea 
sicca, psoriasis, and other cutaneous affections of the scalp; the 
asymmetrical tonus being more common in asymmetrical scalp 
diseases, such as those resulting; from the destructive action of 
the vegetable parasites. Rarely, however, asymmetrical sebor- 
rhoea, occurring in patches upon the side of the head, may pro- 
duce such disfigurement. Among the systemic disorders which 
have this effect, may be named almost all severe fehrile pro- 
cesses, including the exanthemata, profound disorders of the 
nervous centres, lepra, and syphilis. In the last-named disease 
it may occur as a precocious or tardy symptom, the former being 
always symmetrical, variable as to the degree of loss, rarely so 
severe as to cause baldness, and occurring, as it does usually, in 
early adult years, generally quite remediable The tardy form, 
on the other hand, is usually associated with the evolution or 
destructive involution of gummata of the scalp, and the resulting 
baldness is often permanent. 

The forms of alopecia described above as encountered upon 
the scalp, may involve also other hairy portions of the body, as 
of the axillae and pubis; and these also in variable degrees. 

Treatment. — The treatment of alopecia in general, is that which 
stimulates the nutrition of the hair follicle by producing in its 
periphery a species of transitory and artificial hyperemia. This 
is usually accomplished by friction of the scalp with a brush, 
aided by the local employment of alcoholic, oily, alkaline, and 
other stimulating applications. The general health must in such 
cases receive special attention. I am strongly impressed with 
the fact that a large number of individuals suffering from pre- 
mature baldness have a distaste for fat; and the ingestion of 
cod-liver and other nutritious oils, fat meat, or linseed and lin- 
seed oil, as recommended by Sherwell, is for such patients ad- 
visable. Under the most favorable circumstances, however, the 
prognosis of idiopathic premature alopecia is well-nigh as hope- 
less as that of the senile forms. A scanty crop of short, soft, 
downy hairs may push for a time to the surface, but soon yield 
before the inactivity of the follicles in which they are implanted. 
Inasmuch, however, as exceptionally brilliant results are occa- 
sionally obtained by treatment, the latter is always deserving of 
a trial. When the alopecia is symptomatic of some local disease 
of the scalp, the latter of course is first to be relieved by the 
measures, appropriate for each, as, for example, the use of para- 
siticides in those of parasitic origin. The total or partial sym- 
metrical losses of hair occurring in the course of systemic 
disorders, have a much more hopeful prognosis. Exception, 
however, is to be made of the tardy syphilitic alopecia asso- 
ciated with local scalp lesions or profound cachexia. In all 
forms of syphilitic alopecia, local as well as constitutional treat- 
ment is indicated. 



ALOPECIA AREATA. 333 

Alopecia Areata. 

Deriv. Lat. area, a vacant space; (arere, to wither, Fox.) 
Alopecia areata is a disease of the pilaiy follicles characterized by the sudden oc- 
currence of general and symmetrical, or partial and asymmetrical baldness, the 
latter exhibited in distinctly circumscribed, smooth, whitish patches, which 
are, in typical cases, completely destitute of hair. 

Symptomatology. — The disease commonly begins by the sudden 
and complete loss of hair over a circumscribed patch, usually 
upon one side of the scalp, so rapidly effected that patietits often 
describe a first discovery of the fact at the toilet of the morning. 
After a variable period of time, other patches of baldness may 
occur, all of the hairy portions of the body being liable to the 
affection, the scalp first in order, next the beard of the. male, 
then the genitalia, axillae, brows, lids, and the general surface 
of the body. I have seen a female child twelve years of age, 
where the closest scrutiny with a glass could not detect a single 
filament of hair upon any portion of the skin. 

The patches may be roundish, ovalish, or irregularly shaped, 
and may vary greatly in size, from that of a small coin upward. 
They may be so numerous as to greatly disfigure the entire scalp; 
and though these touch at the borders when thus numerous, they 
can scarcely be said to coalesce, as the individual elementary areas 
are usually recognizable. Their surface is smooth, whitish, and 
often perfectly destitute of hairs; it is rarely tumid and slightly 
reddened. The hairs at the periphery are usually of full length 
and fixed in situ, but are occasionally fragile, and readily with- 
drawn from their follicles. Stumps of such friable hairs may be 
at times seen at the margin of the patch. In point of abnormal 
subjective sensations, temperature, or disease of the surface from 
which the hairs have fallen, there is, as a rule, complete absence 
of symptoms. The skin, when the evolution of the disease is 
complete, is usually natural to the touch, and pliable. In in- 
complete evolution, and in periods of repair, downy hairs may 
appear upon the surface, at times considerably differing in color 
from those springing from unaltered regions of the scalp. 

The loss of hair from the surface may be: rarely, gradual; 
preceded by mild pruritus (Besnier et Doyon); or followed by 
anaesthesia (Neumann). Its apogee once attained, the course of 
the disease is variable; it may persist for periods without appa- 
rent change; or new patches may form while those of an older 
date either proceed to reproduce wholly or in part the pilary 
growth ; or, this latter accomplished, suffer a fresh loss by relapse. 
[Shifting areas of the disease may without question in this man- 
ner invade the entire surface of the scalp, which yet at any one 
moment of time may exhibit a loss of but the half of its hirsute 
covering. 

There is some reason for believing that the disease has a rela- 



334 DISEASES OF THE SKIX. 

tively fixed period of evolution, though the exact limits of tlie 
latter are no1 known. Few individuals suiter less than one year; 
the moat arc relieved within a period of two years. These 
remarks, however, apply to the asymmetrical forms of the dis- 
ease in the relatively young. The symmetrical alopecia areata 
of the middle-aged is,' in my experience, a far more formidable 
affection. 

Few discuses are the source of greater mental distress than 
those of the Hass now under consideration. The prominent 
deformity thus occasioned debars the subject of the malady from 
social relations of many kinds, and this intensifies the morbid 
feeling which every reflected view of the head awakens. This 
is particularly true* of women. The successful management of 
these cases calls often for the supporting assurances of the 
practitioner. 

Etiology. — The causes of the disease are unknown. It is not 
transmitted by heredity nor by contagion ; and is not due to 
the presence of a parasite. It occurs with equal proportion in 
the two sexes ; and among these, irrespective of social condition. 
Of the partial and asymmetrical forms, I am persuaded that the 
larger number of cases occur in young subjects, from childhood 
to 'early adult life. The severe and generalized forms, I have 
more often encountered in middle-aged persons. In the latter 
elass especially, it is occasionally observed to follow the obscure 
disorders of the nervous centres due to sudden or prolonged 
undue excitation. In young subjects, I have repeatedly disco- 
vered a peculiar repugnance to the ingestion of fat and meat, a 
point to which attention is called in considering alopecia simplex. 

Collier 1 cites two cases in which the disease followed a blow 
upon the temporal region. 

Pathology. — The anatomical lesions which produce alopecia 
areata have not been recognized. The hairs fallen from the sur- 
face, when examined with the microscope, are seen to be atro- 
phied in the bulb and shaft, though Rindfleisch describes in 
certain cases a node-like enlargement of the hair-shaft after its 
escape from the follicle. Fracture of the shaft is in some cases 
also noted, evidently an accident of the process. No parasite 
can be discovered in uncomplicated cases. I have in one instance 
detected spores and mycelia of the trichophyton in the hairs, a 
coincidence of two disorders which has been observed by others. 

In default of all positive knowledge on the subject, the ma- 
jority of dermatologists have assumed the disease to be a tropho- 
neurosis, a view sustained by the etiological history of certain 
cases. I am inclined to believe that future investigation may 
establish some difference other than that of degree, between the 
partial asymmetrical disease of the young, and the more general 
symmetrical affection of middle life, in which the entire scalp, 

' Lancet, Am. ed., Aug. 1881, p. 130. 



ALOPECIA AREATA. 335 

lids, brows, pubis, and axillae, are completely shorn of their 
filaments. 

Diagnosis. — Alopecia areata is to be distinguished from vitiligo 
of the hairy portions of the surface, by the preservation of the 
pilary growth in the disease last named, the filaments moreover 
having usually a blanched and whitened look, due to the absence 
of pigment. 

From ringworm and favus of the scalp, the disease in question 
is readily differentiated, by the suddenness of its onset; the 
absence of all stumps of hairs, scales, crusts, and evidences of 
irritation in the involved area ; the whiteness, smoothness, and 
complete baldness of the latter; and, above all, by the failure 
to detect with the microscope the evidence of the presence of a 
vegetable parasite. 

The rare asymmetrical patches of seborrhcea of the scalp, are 
recognized by the presence of the fatty plates pasting the hairs 
to the surface, as well as by the slow and very gradual onset of 
the disorder. 

Other forms of baldness than those named above are all of 
gradual and, in their early stages, of symmetrical development. 
Those resulting from traumatic injuries of the scalp with cica- 
tricial results, are easily determined as having such an origin. 

Treatment. — One must necessarily view with some distrust all 
treatment for that disease which in the course of months or 
years usually terminates in spontaneous recovery, and in the 
mean time seems to bid defiance to each and eveiw therapeutic 
measure. Nevertheless, persistent and hopeful management of 
even the apparently desperate cases, is occasionally rewarded by 
such brilliant consequences that, however slight may be the 
foundation for a belief in the value of the therapy employed, it 
deserves recognition and trial. 

The indication for local treatment is to increase the physio- 
logical afflux of blood to the hair-follicles. With this end in 
view, the affected parts are to be bathed daily in water as hot 
as can be tolerated, then dried, and scrubbed with a stimulating 
lotion. The articles usually employed are alcohol, ether, tur- 
pentine, ammonia, camphor, cantharides, carbolic acid, oil of 
mace, croton oil, tincture of mix vomica, tincture of capsicum, 
tincture of aconite, castor oil, tar, iodine, sulphur, and the mer- 
curials. All frequently fail. Several of these in combination 
seem at times to be of service. 

The following are formulae, th 
varied to suit the indications in different cases: — 



. 01. ricini 


fgss; 


16 


Acid, carbolic. 


3j; 


4 


Cantharid. tinct. 


gss; 


16 


01. rosmarin. 


gtt. xv ; 


1 


Spts vin. rectif. 


adfgiv; 


130 



S. For external use over the scalp with friction. 



336 DISEASES OF THE SKIX. 

r. Oi. terebinth., ] ..- f - . 1fi 

01. ricini, s' 1,1, lb 

Origani tinct. f 3j ; 4 

01. caniphorat. f ;j ; 30 ' 

Liniment, volatil. ad f giij ; 100 11 

Sig For external use with a brush till the scalp is irritated. 

Repeated blisterings of the scalp with cantharidal collodion, 
the Bpirit of green soap, and petroleum have also been employed 
externally with success. I have used with satisfactory results 
in a lew eases, an ointment of chrysarobin, which has the dis- 
advantage of staining not only the remaining hairs, hut often 
the face in consequence of its transmission to that locality by 
the medium of the hands. When patients, however, consent 
to its use, it is worthy of a trial, as its application has been 
speedily followed by a vigorous growth of new pilary filaments. 
Andre 1 employed ten hypodermic injections of muriate of pilo- 
carpine in one-eighth grain (.008) doses, which resulted, in the 
ease of a middle aged woman affected with total symmetrical 
baldness, in an abundant growth of hair. 

The disease, when limited to the regions of the beard in the 
young male, usually concludes its stadium in the course of 
about one year, with a favorable termination. Shaving should 
be regularly practiced, as the deformity is thus rendered some- 
what less conspicuous ; and the bald surface should be frequently 
stimulated with one or several of the topical applications named 
above. Alcoholic solutions of the mercuric bichloride, half to 
one grain (.033-.066) to the ounce (32.) are to be well rubbed 
over the patch or patches, once or twice daily. I have seen the 
disease in this locality coexist in two cases with benignant 
syphilis, the latter disease pursuing a career considerably short- 
ened by vigorous treatment, while the former, none the less, 
endured for twelve to fourteen months, long after the syphilitic 
cachexia had been relieved. At the end of this time, recovery' 
occurred precisely as in those cases which had presented no his- 
tory of infection. 

In all cases of implication of the head, where the scalp is in- 
volved in either sex, and where the peculiar hypochondriasis of 
the disease is developed, a wig should be worn for the sake of 
its moral effect upon the sufferer. For such, however, its use 
should be limited to social occasions, visits, etc., as the persistent 
wearing of a perruque in-doors, has seemed to me to lengthen 
somewhat the course of the disease. 

Internally, the use of fats and oils, especially cod-liver oil, is 
generally to lie advised ; and the chalybeate tonics with arsenic, 
quinine, and strychnia will often serve an important end. 

Prognosis. — From what precedes, it will justly be inferred 
that, as regards the relief of the baldness, the asymmetrical de- 
velopment of the patches in youth is much more favorable than 

I Rev. M§d. Fran, et Etranc. 



ATROPHIA PILOKUM PROPRIA. 837 

the symmetrical general disease of middle life, the latter being 
often hopelessly remediless. The prognosis of the same affection 
of the male beard, is quite favorable. In all cases, the practi- 
tioner should actively persevere to the end. In no case should 
any encouragement be given as to complete relief within the 
year, though such exceptionally short careers of the disease are 
at times observed. 

Alopecia Furfuracea. 

Pityriasis Capitis. 

Under this title, is included that loss of hair, varying greatly 
in degree from moderate thinning of the growth to considerable 
symmetrical baldness, usually of the vertex, which, at the onset, 
results usually from seborrhcea. The scalp symptoms of this 
disorder have been described in the chapter devoted to sebor- 
rhoea. Later, however, as a consequence of long-continued ca- 
tarrh of the sebaceous glands, there is secondary involvement 
of the epidermis, whose elements are produced and shed in 
pathological frequency. The scales are then true squamae; dry, 
corneous, and epithelial, rather than fatty and seborrhceic. The 
subjective sensations are usually marked ; the scalp is often 
scratched and torn by the nails, and is in some eases reddened 
and thickened. There is, as a rule, decided general cachexia. 
Thus seborrhcea of the scalp is often associated with a general 
condition of excellent health ; alopecia furfuracea, never. The 
patients are often nervous, sallow women, with a long history 
of distressing headache, uterine hemorrhage, or hepatic disor- 
der. These are simply states in which there is malnutrition of 
the scalp. 

The treatment is that of seborrhcea and alopecia, as already 
described, with the internal remedies indicated by the general 
condition of the patient. 

Atrophia Pilorum Propria. 

Atrophy of the hair may be either symptomatic or idiopathic. 
Illustrations of the first named condition are observed in 
phthisis, syphilis, seborrhcea, ringworm of the scalp, and almost 
all general diseases interfering with the nutrition of the pilary 
growth. The filaments then become dry, lustreless, friable in 
both longitudinal and transverse diameters, and diminished in 
each dimension. 

There are several recognized forms of idiopathic atrophy of 
the hair. One of these exists in those long hairs which are seen 
to be irregularly thinned or flattened in the shaft, and split at 
the point into two or more recurving fibrillse, a condition noted, 
for the most part, in few hairs scattered among those of full 
development aud vigor. This especially localized atrophy seems 
22 



338 DISEASES OF THE SKIN. 

to be peculiar to one or more follicles merely; and is quite anal- 
ogous to the condition in which there appears among the vigor- 
ous pigmented haira of early life, a single blauched filament. 

Under the title of " An Undescribed Form of Atrophy of the 
Hair of the Beard," Duhring 1 gives the details of an exceed- 
ingly interesting case, in which either at the bulb or at a variable 
distance fr >m it hut within the follicle, there was fission of the 
hair filament into from two to four stalks with coincident 
atrophy of the bulb itself, and consequent irritation of the sur- 
face. The patient exhibited to a marked degree the species of 
hypochondriasis, to which the subjects of disease of the hair seem 
specially prone. Through the kindness of the author, I had the 
opportunity of privately examining under the microscope some 
specimens of these hairs, the appearances of which are admirably 
portrayed in the woodcut which illustrates his paper. This dis- 
order is not induced by a parasite. 

Trichorexis Nodosa, 

first described by Wilks and Beigel, is a condition in which 
the baits display "nodose swellings along the shaft at irregular 
distances, the beard and moustache being most often affected, 
thoush rarely there is involvement also of the hairs of the scalp. 
Sherwell, 2 in this country, has described one such case. The 
hairs are brittle; and fracture usually occurs through the node, 
leaving a broom-like mass of filaments projecting there, while 
the internodular portions of the shaft, appear normal save for 
some enlargement of the medulla. The fragility of the hair at 
the centre of the node, seems to depend upon the tension and 
consequent fissure of the cortical layer which is greatest at that 
point. No parasite has been discovered in hairs thus affected, 
their bulbs, moreover, being firmly adherent in their follicles. 
Little is known as regards appropriate treatment of the disease, 
which is, it must be said, persistent and disfiguring. Shaving 
has been followed in some of Kaposi's cases by good results; 
while Roeser 3 advocates the local employment of dilute tincture 
of cantharides. 

Smith, 4 of Dublin, has also reported a curious case of nodose 
SWELLINGS of the shafts of the hairs, differing somewhat from 
those described above. Through the kindness of Dr. Duhring, 
I have been enabled to exhibit some of these hairs in Chicago, 
photo-micrographs of which were, at my suggestion, taken by Dr. 
Belfield, of this city. Here there was no fragility at the nodes, 
which commencing near the scalp were quite regularly displayed 
along the shaft, the fracture being always internodular. The 

' Amir. Jour, of the Med. Sci., July, 1878. 

« Arch, of Derm., July. 1879. 

» Annal. de Derm, el de Syph., 1877-78, pp. 185 et seq. 

* Brit. Med. Jouni., May 1, 1880. 



ATROPHIA PILORUM PROPRIA. 



339 



spherical swellings along the shaft were also pigmented in a 
brown hue, and these, contrasting with the non-pigmented color 




Tricliorexis nodosa. (After Schwimmer.) 



of the unaffected portions of the shaft, gave the hairs a singularly 
"checkered" appearance. ]S"o parasite is discernible iu any of 
the specimens. 



340 DISEASES OF THE SKIN. 



Piedra 

"ense 



is described as still another condition of the hairs in which d .. 
node-like masses are attached to or surround the hair Bhaft. 
Mon-is 1 describes these as containing masses of spores. In a 
single case, thai of a young girl Bent to me by my colleague, Dr. 
Holmes, of the Eye and Ear Infirmary, I discovered there were 
numerous, jet-black, horny, and dense spherical masses attached 
to the liaii-sot' the eyelashes of each lid of both eyes. I \v;is 
unfortunately prevented from securing some of those hairs for 
microscopical examination. 

Canities. 



•ees 



Canities is that condition of the hairs in which they become in various deg 
decolorized as the result of atrophy of their pigment. 

Symptomatology. — Hairs appear in all shades of whiteness, from 
dirty-gray to silvery white, and this either as a general or par- 
tial, congenital or acquired, physiological or pathological, pre- 
mature, rapidly or gradually acquired condition. General con- 
genital whiteness of the hairs is seen in albinism, where pigment 
has never been supplied to the filaments. Partial congenital 
whiteness is occasionally seen, in meshes limited in size, varying 
in color from a pure white to a deeper hue, which from birth 
refuse to receive pigment in due proportion, and thus contrast 
strangely with the pigmented filaments by which they are sur- 
rounded. 

Physiological decoloration of the hairs in variable shades, is 
the well-known result of advancing years. When premature, it 
may he considered as resulting from pathological causes, or due 
to other individual or inherited peculiarities. It may occur 
gradually or suddenly; in the former case, the hairs usually pass 
through variable shades of gray to white, and this at any period 
after puberty, though usually after middle life is reached. 
Recurrence to the darker shades is rarely noted. Leonard, of 
Detroit, 2 cites a number of curious instances in which changes 
of this sort have occurred. Generally, however, canities of ad- 
vanced years is progressive and permanent, occurring earliest 
on the temples, then involving the vertex of the head. Finally, 
the hairs of the entire surface undergo a similar pigmentary 
loss. 

It should be remembered that the coloring of the hairs of the 
head is, to a greater extent than is commonly appreciated, sub- 
ject to variation from the operation of external causes. Thus 
washing the hair with alkaline solutions has a bleaching effect, 
while profuse sweating, inunction with fats, subjection to smoke, 

1 Lancet, Dec. 7, 1878. 

2 The Hair, etc., Detroit, 1880. 



SYCOSIS NON-P ARASITICA. 



341 



and the temperature changes of the summer, have the contrary 
effect, the last named being possibly due to the increased sweat- 
ing in the hot season. 

Treatment. — The sole means of remedying premature canities 
is by the action of dyes, and these are, in the main, compounded 
of solutions of nitrate of silver, acetate of lead, and the sulphate 
of iron. The chief objections to their use are the disagreeable 
coloring of the scalp which results from incautious use of the 
dye, and the consequent liability to irritation of the surface. 
When applied to the hair alone, these substances are not known 
to have a deleterious effect upon the health. Kaposi gives the 
following formulae for hair dyes: — 

To obtain a black color — 



Argent, nitrat. 
Amnion, carb. 
Unguent, adipis 



or, 



ty. Argent, nit. 
Plumb, acetas 
Aq. Cologn. 
Aq. ros. 

To obtain a brown shade- 
1$. Acid, pyrogall. 
Aq. Cologn. 
Aq. ros. 



gr. xv ; 

grs. xxij ; 

Sj; 


33; 

gr. xv ; 
gtt. xv ; 
ad f.%iij ; 


gr. xv ; 
p;ss ; 
SJss ; 



01 

II 

1 

100 



M. 



M. 



2. Exudative. 

Sycosis Non-Parasitica. 

Derio. Gr. s-Skov, a fig. 

Sycosis non-parasitica is an acute or chronic inflammatory affection of the sur- 
faces provided with relatively long hairs, in which the follicles and perifollic- 
ular tissues are involved in an exudative process, producing papules, pustules, 
tubercles, infiltrated patches, and crusts perforated by hairs. 

Symptomatology. — This affection usually occurs upon the face, 
involving one or both cheeks successively or simultaneously, the 
chin, upper lip, eyebrows, scalp, axillae, and pubes. The first 
symptoms are usually the occurrence of several discrete, flattened 
or conical, reddish and painful papules or pustules, whose ana- 
tomical seat is recognized to be the hair follicle by the penetra- 
tion of each by a filament of hair. These lesions may persist, 
and when typically discrete and visible at the part where the 
hair makes its exit from the duct of the follicle, have suggested 
the appearance of the surface of the tig, whence the disease has 
its name. They are apt to occasion a burning and at times a 
decidedly pruritic sensation when, being picked or torn open by 
the lingers, the pus concretes into a crust at the base of the hair. 



342 DISEASES OF THE SKIN. 

Involution of Beveral lesions may be followed by fresh crops 
and, :i> a rule, Booner <>r later distinct patches of disease are thus 
formed. When fully developed, the surface of the skin is red- 
dened, swollen, infiltrated and thickened, covered irregularly 
here and there with papules, pustules, crusts, scales, ana" often 
with excoriated surfaces. The disease is apt to lapse into chronic 
conditions, usually as the result of improper treatment; and in 
ancient cases the deformity is characteristic and totally unlike 
that produced by the vegetable parasites. The hairs are usually 
fixed firmly in their follicles, hut from those where active sup- 
puration is in progress, they may be plucked without occasioning 
much pain. In the eases which have been treated for years, the 
hairs are thin and decidedly lacking in vigor. There is no par- 
asite to he discovered. 

In typically neglected cases of longstanding, where the region 
of the male heard is involved, an important clinical feature is 
the symmetrical, general ami uniform involvement of the entire 
surface. The picture of one cheek is very nearly that of the 
other. The thin hairs scarcely serve to disguise the reddened, 
tumid, painful surface beneath, displaying the several lesions of 
the malady. Furuncles, abscesses, cicatrices, vegetations, and 
eczema of the ears may complicate the process. It is occasion- 
ally acute in its course, but more often chronic and rebellious. 
I have never seen a typically chronic and untreated case of the 
malady terminate by spontaneous involution. 

Etiology. — The exciting causes of the disease are often obscure. 
It is encountered chiefly among males after puberty, and these 
in all social conditions and grades of health. It is non-parasitic, 
non-contagious, and not transmissible by heredity. Shaving is 
not known to produce it. At times, the immediate cause of the 
disease can lie recognized; as when the upper lip is constantly 
irritated by the discharge from a profuse nasal catarrh. I have 
treated one such patient, two years after Ilebra first assumed 
charge of his case. In others again, all the causes of eczema 
may be invoked in explanation of the result. 

A careful study of many of these cases has, however, con- 
vinced me that the hairs themselves are the aggravating causes 
of the disease and the sources of its peculiar obstinacy. In 
health the motions of the free shaft of the hairs do not irritate 
the follicle in which it is set. In conditions of disease it is 
quite different. Each free hair operates like a lever upon the 
inihuned ring of tissue which encircles it on its escape from the 
follicle beneath, and this whenever by the touch of the hand, 
by the action of brushing, by currents of air, or by any agency 
whatever, a movement is imparted to it. Every such movement 
must tease to a variable degree the surface beneath already 
irritated, and when estimate is made of the hundreds of such 
movements to which each hair is subjected during a period of 



SYCOSIS NON-PARASITICA. 343 

twenty-four hours, the relative importance of this apparently 
insignificant factor may be appreciated. 

Pathology. — The disease is due to an inflammatory process, 
which, whether originally follicular or peri-follicular in its seat, 
may extend unquestionably either toward or from the follicle. 
Sometimes the extraction of the hair is followed by a drop of 
pure pus, which exudes from the follicle; and the root-sheaths of 
the hair are seen to be altered in consequence of the circum- 
scribed follicular abscess. At other times, the follicle itself is 
free from disease, and the exudative process has evidently ex- 
pended itself upon the peri-follicular or even the inter-follicular 
tissues, in which case the papillary layer of the derma exhibits 
the usual phenomena of hyperemia, infiltration and multiplica- 
tion of protoplasm, with abundant vascular dilatation. 

Diagnosis. — The most important consideration here, is the 
distinction between the parasitic and the non-parasitic forms of 
the disease, upon which naturally the microscope finally decides. 
Still the clinical features of the diseases are quite distinct. The 
non-parasitic form is recognizable by, (a) the greater redness 
of the involved surface; (b) by the extension of the disease in 
advanced cases to larger areas of sj^mmetrical involvement; (c) 
by the more superficial character of the lesions, and (d) by the 
firm implantation of the hairs in their follicles in the earlier 
periods of the disease, and their relative freedom in all cases 
from fracture and relics in the form of stumps. The parasitic 
disease of the hairs is peculiar, in consequence of (a) decidedly 
less redness of the surface attacked ; (b) its frequent limitation 
to a circumscribed area, or to several such, irregularly dispersed 
over a large region; (c) the peculiar "lumpy, tubercular, nod- 
ular, and uneven" characters of the patch, upon which Dun- 
ring has laid significant emphasis; and id) the earlier loosen- 
ing of the hairs in their follicles, as also of the occurrence of 
fractured hairs and stumps, exhibiting, usually at the bulb, un- 
mistakable evidence of the nature of the disease. The malady 
is often mistaken for syphilis, chiefly on account of its deformity, 
but the pustular syphiloderm is very much less chronic in its 
course, is never limited for years to the face exclusively, and 
when long persistent in one locality, is characterized by ulcera- 
tion and the production of very characteristic crusts. 

Eczema may complicate non-parasitic sycosis ; but typical in- 
stances of the two disorders may be recognized by the occur- 
rence, in the former case, of a discharging disease not usually 
limited to the region of the beard, characterized by a more in- 
tense itching, and with marked absence of the papulo-tubercular 
lesions described above. 

Treatment. — In all cases of non-parasitic sycosis, the essential 
and important step is the continual removal of the hairs which, 
as indicated above, are the chief sources of aggravation of the 
disease, f This is best accomplished by shaving, an act which, 



344 DISEASES OF THE SKIN. 

though often painful at the onset, is soon well tolerated by tlie 
Bufterer. The majority of patients, however, object to the re- 
raoval of the beard, far more on account of tin- consequent greater 
cxi osure to view of the deformity induced by the disease (then 
no longer partly masked by the whisker) than on account of the 
dish..-- occasioned by the operation. To these objections, there 
is hut one response. The shaving is essential; the deformity is 
rapidly reduced alter its successful initiation; the discomfort 
diminishes with each repetition of the process. For the die 
in patients positively refusing to have the beard removed, whose 
cas< - are bo severe as to require it, the practitioner will do well 
to decline to he responsible. There is no limit to the tedious 
and obstinate course of the malady in the one case ; and in the 
other, the results are speedily satisfactory, often in the course of 
a few weeks. 

When there is much tenderness, pain, swelling, pustulation, 
or crusting, the hairs may first be clipped short, and a bland 
poultice applied, of oil, elm-bark, or bread and milk. The prac- 
tice in Vienna, is to substitute for the latter, strips of soft mus- 
lin or linen spread with diachylon ointment and firmly bandaged 
over the cheeks, chin, or lips, for from twelve to twenty-four 
hours, after which the razor is passed over the entire surface. 

The integument which thus becomes visible, is usually a red- 
dened infiltrated area, with pustules, papules, pustulo-papules, 
and some crusts dispersed here and there over it. This is best 
treated by very hot water lotions, pure or alkalinized, after exit 
is given to all purulent collections; and then a bland ointment 
is to lie applied at night, and a dusting powder in the morning. 
The subsequent treatment is largely that of eczema of equal 
grade of severity. In the more acute periods, the oleated lime- 
water, medicated with calomel or zinc oxide, half to one drachm 
(2.-4.) of either to the pint (500.1 may often be employed with 
hen. lit; or for this may be substituted two ounces (64.) each of 
linseed oil, castile soap, and paraffine, to the pint (500.) of aqua 
calcis. Later, ointments may he used, particularly cold cream, 
to which either sulphur, the zinc oxide, or, less preferably, one 
of the mercurials may be added. Lotions of the mercuric bichlo- 
ride, sulphur, alcohol, Cologne water, or iodated glycerine, may 
lie useful in stimulating any indolent patches of infiltration. 
The treatment of these is indeed that of chronic eczema. 

In Vienna, epilation is successfully practised for relief of the 
disease ; and, by many, severer met hods are employed, including 
the use of green soap, tar, cauterization with acetic, and even 
nitric acids. Erasure with the curette is to be named in the 
same category. It is possible that these measures have been 
employed in much more aggravated cases than those commonly 
observed here; but as the disease is certainly curable in a ma- 
jority of cases without having recourse to these heroic methods, 
they are to he regarded in the light of ndcrnier ressort. I never 



SYCOSIS NON-PARASITICA. 345 

find it necessary in non-parasitic forms of sycosis, to either epi- 
late or employ caustics. By repeated and frequent use of very 
hot water, and the milder stimulants, with constant shaving, 
the desired result is always within reach. Shaving should be 
continued for nearly one year after all traces of the disease have 
disappeared ; and it is a point of some importance to substitute 
a continuously applied dusting powder for a fatty application, 
so soon as the skin will tolerate the persistent use of the former. 

Internally, treatment is of minimum value, and when indi- 
cated, should be of the kind demanded by the wholly accidental 
constitutional condition of the patient. It is a matter worthy 
of special attention, however, to purge every previously treated 
case of all suspicion of an artificial element, by withdrawing 
for a proper time all internal medication. The disease is so dis- 
figuring that many patients swallow the iodide of potassium, 
arsenic, and other deleterious drugs for months before consult- 
ing one who is wiser than they in these matters. Exposure of 
the face to dust, smoke, wind, and other sources of irritation 
should be for a time avoided. 

Prognosis. — The disease is entirely curable, and will, in the 
large majority of all cases, either disappear entirely or be very 
greatly improved by judicious treatment. The latter requires 
the personal supervision of the physician and close attention to 
details. 

Dermatitis Papillaris Capillitii. 

Under this title Kaposi describes a disorder characterized by 
pin-head sized, isolated or confluent elevations of the surface, 
with interspersed pustules, which finally form cicatriform plaques 
over which the hairs are either clustered in tufts or totally ab- 
sent. The pilary filaments are atrophied, yet firmly fixed in 
their follicles, and suffer elongation or fracture before with- 
drawal. The disease is encountered chiefly upon the nucha, 
occiput, and vertex. Papillomatous vegetations, crust-covered, 
hemorrhagic, and with a foul-smelling secretion, sometimes 
form, and eventually retract into a sclerotic tissue. 

I have seen two typical cases of this disorder, 1 and each 
concluded with the production of a keloid-like, cicatriform, ir- 
regularly shaped, but circumscribed elevation of the surface. 
This feature is that by which it specially differs from all other 
sycosiform disorders. The disease is, I believe, due fully as 
much to inflammatory processes in the subcutaneous tissues 
between the unyielding pericranium and the thick scalp, as to 
the derma proper, and is not, therefore, strictly speaking, a 
dermatitis. Puncture, for example, of one of the pin-head sized 
pustules, usually gives exit to the usual quantity of pus, but 
pressure upon the scalp in the periphery will at once be followed 
by the appearance of a still larger quantity of similar pus, which 

1 See a paper on this subject by the author, published in the Joum. of Cuta- 
neous and Venereal Diseases, vol. i. No. 2, p. 83. 



346 DISEASES OF THE SKIN. 

evidently is expressed from a circumscribed subcutaneous ab- 
When by Bucb pressure the abscesa cavity is emptied, it 
Blowly tills with venous blood, and produces a firm, semi-solid 
elevation of the Burface, which subsequently undergoes sclerosis, 
and the Btarved hairs above behave in the manner well described 
by Kaposi. The papules and plaques arc formed in a similar 
way, by the abundant supply <>t venous blood. The case of one 
of my patients (presented at the clinic) had been erroneously 
diagnosticated by a Burgeon ;is aneurismal in character. Punc- 
ture of all Buch semi-solid, cicatriform lesions, is invariably fol- 
lowed by oozing of venous blood in abundance. The disease is 
chronic in character, particularly liable to relapse in crops of 
pilary or peripilary pustules and papules, and extends from 
nucha to vertex, curiously avoiding the frontal and temporal 
regions. Over the bald or partially bald, keloid-like elevations, 
there is occasionally seen a species of seborrha-a in the form of 
more or less adherent, fatty crusts, with occasional characteristic 
tufts of hairs. None of these hairs were invaded by a parasite, 
though repeatedly examined with the microscope with a view 
to such discovery. 

I believe that the disease owes its peculiar character to the 
anatomical peculiarities of its location. It occurs preferably at 
the points where the venous supply of the scalp is not only 
greatest, but in most direct connection with the large vessels 
beneath, and where an inflammatory process in the derma or 
subcutaneous tissues, invites with readiness a pathological afflux 
of blood. Such a focus, limited beneath by the dense calvarium, 
and with the relatively thick scalp above, readily undergoes 
organization and sclerosis; the subsequent behavior of the hairs 
and hair-follicles being an accident of the process. The method 
of treatment to be employed in this rare disease, the exact 
nature of which is, indeed, not yet appreciated, can scarcely be 
said to be established. 

Sangster (in a paper read before the International Medical 
Congress in London, 1881) described a pigeon's egg-sized tumor 
of the scalp, which Kaposi, who was present, recognized as a 
case of dermatitis papillaris capillitii. 

3. Hypertrophic. 

Keratosis Pilaris. 

Keratosis pilaris is a disorder, chiefly of the extremities, characterized by 
multiple, millet-seed sized, whitish, grayish, or slightly reddish aggregations 
of epithelium, about the orifice of the hair-follicles. 

Symptomatology. — This condition, termed also lichen pilaris, 
may he a mere temporary and functional disturbance of the 
skin, awakening no subjective sensation, inappreciable by the 
patient, and apparent only to the careful observer, or it may 



KERATOSIS PILARIS. 347 

realty constitute a disease. Its symptoms are the occurrence of 
pin-bead sized, pointed elevations of the surface, which may be 
described as papules, though, strictly speaking, they are not 
such, constituted by an accumulation of horny epithelia, and a 
small quantity of inspissated sebum about the lanugo hairs of 
the extensor surfaces of the extremities and trunk. These aggre- 
gations of material are usually of a dirty-whitish or grayish hue, 
and pierced by a lanugo hair implanted in the follicle, about which 
the abnormal condition exists. Occasionally, however, the hairs 
are of the finer and shorter kind, and are often coiled in or 
otherwise covered by the little heaps of epithelial debris. The 
skin of the individual thus affected is generally harsh, squamous, 
and dry to the touch ; being also, in the majority of cases, long 
unwashed. The color of the quasi-papules also differs with the 
complexion of the individual ; at times they have a distinctly 
reddish tinge. They are often surmounted by a scale. 

The condition is sufficiently common in skins long uncleansed 
by ablution, and can thus be artificially produced. In some in- 
dividuals it persists for long periods of time, and awakens no 
concern. In others, and especially in children, it speedily be- 
comes the source of a pruritus, and each lichenoid papule may 
be then transformed into an urticarial wheal, with distinct and 
sometimes very annoying, pricking and tingling sensations, the 
entire trouble being at once relieved by a bath in warm water 
with soap. In other cases, especially in adults, an exaggerated 
form of the disease can be recognized, the skin presenting a 
roughness to the touch suggestive of the nutmeg-grater, and ex- 
hibiting numerous fine, conical, grayish, horn-tipped filaments, 
which several dermatologists are disposed to regard as a form of 
ichthyosis. Here, there is doubtless a true hypertrophy of the 
epidermis. In the former case, there is scarcely more than a 
mechanical accumulation of effete organic material. There can 
be but little doubt that the malady, simple though it be in 
character at the onset, may become the first stage of a series of 
chronic cutaneous disorders. Tilbury Fox 1 has reported four 
cases in which the disease was well marked, under the title 
cacotrophia folliculorum, the name being employed to desig- 
nate its peculiarities as to wide distribution over the body, im- 
plication of the deeper portion of the follicles, and its congenital 
history. In these cases, the reddish tint of the lesions is dis- 
tinctly shown. 

The disease should be readily recognized by the peculiarities 
of its seat, its course, and the nature of its symptoms. From 
ichthyosis, it can be distinguished by its limitation to the orifice 
of the hair follicle; from the transitory condition known as 
"■goose flesh," by its persistence after the surface of the skin is 
thoroughly warmed ; from papular eczema and the other lich- 

1 Clin. Society's Trans., vol. xi., with illustration in color. 



348 DISEASES OF THE BKIN. 

enoid eruptions, by the relatively insignificant character of the 
lesions, and their evidenl association with follicular inertia. 

The disease is besl treated locally by warm water and soap 
bath 8, followed, in the more argent eases, by inunction with the 
fats or oil 8. In the congenital and severer cases, such as those 
described by Fox, doubtless cod-liver oil internally should be 
advised. 

Hypertrophy of the Hair. 

Hypertrophy <>t' the hair is a development of the pilary filaments, exaggerated 
as to Bize or number, <«r unusual either with respect to the location of the 
growth, or the age, <>r sex. of the individual in whom it is displayed 

Hirsuties ma} - he congenital, and this in various grades. It 
is sufficiently common to see infants at birth provided with ex- 
tremely long hairs of the hairy parts of the hod}-, such a growth 
being usually replaced later by shorter filaments. Universal 
congenital hirsuties is a rare deformity, the entire body being 
then covered with longer or shorter downy hairs of various 
colors. 

Acquired hirsuties ma} 7 be partial or universal ; much more 
commonly the latter. Thus the hairs of the scalp or heard may 
acquire an enormous vigor and length, reaching fully to the 
ground when the ligure is in the erect position ; or the hyper- 
trophy of the hairs may affect the face of the female, and in this 
sex, either the upper lip, chin, cheeks, or all portions of the face 
usually covered by hairs in the male, be provided with a vigor- 
ously and symmetrically developed pilary growth. Dubring 1 
has reported one such case, which is illustrated by an excellent 
lithograph representing the face of a woman provided with a 
superb beard. 

In such cases, the growth may he variously colored, and the 
hypertrophy of downy hairs be purely numerical, or result in 
increase in the actual size of the shaft of individual filaments. 
In neither case do the hairs present any anatomical peculiarities 
of structure. The localized congenital and acquired forms of 
hirsuties, are often characteristic of certain moles, known as 
N.Kyi pilosi ; and are also at times seen to cover the surface of 
pigmentary moles (n/evi plcmentosi). 

Under the name plica poloxica, was formerly described a 
condition supposed to l>e a disease peculiar to the Poles (whence 
its name!, but which has long been recognized as a result merely 
of persistent neglect, filth, the invasion by parasites and conse- 
quent exudative disorders, of the scalp. When it exists, the 
hairs form a huge matted mass on the crown of the head. 
Hebra has devoted some interesting pages to the superstitious 
awe with which this accumulation of hairs and tilth has been 
regarded. .Dr. II. M. Bannister, lately connected with the U. S. 

" Arch, of Derm., April, 1S77. 



HYPERTROPHY OF THE HAIK. 349 

station in Alaska, informs me that be has seen a number of 
cases of plica among the inhabitants of that region. That is 
probably the sole territory of the United States where it exists. 

Etiology. — When congenital or acquired, the causes of hirsuties 
are practically unknown. It is clear that whatever determines 
the blood in excess to any one portion of the body, may be in- 
directly the cause of hypertrophy of the hair, a fact demonstrated 
in many patients of middle life who, after applying sinapisms or 
liniments for many years to the skin over the seat of a rebellious 
neuralgia, exhibit an abundant growth of hair, often several in- 
ches in length, over a scapula or a buttock. In women, whose 
sex renders the anomaly most deforming and distressing, it is 
chiefly noted at the beginning and end of the sexual life. At 
times female patients of this class suffer from disorders of the 
sexual apparatus, but I believe this to be quite unconnected with 
the disease. It is decidedly more common in brunettes. 

Treatment. — To Hardaway, of St. Louis, Americans are in- 
debted for the popularization of the method of removing super- 
fluous hairs by electrolysis, first devised by Michel, of his city. 
After him, White, of Boston, Duhring, of Philadelphia, Heitz- 
mann, Fox, and Piffard, of New York, and others have with 
success removed thousands of hairs, and without subsequent 
reproduction of the growth. A fine needle is introduced into 
the hair-follicle and pushed well down to the papilla at its base. 
This instrument is connected with the negative pole of a gal- 
vanic battery containing from six to twelve elements, the posi- 
tive pole of which is in connection with a sponge electrode held 
in the patient's hand ; the latter being thus enabled to make or 
break the circuit at will. When the current is passed, a few 
minute bubbles of gas escape from the orifice of the follicle, 
and, when the hair papilla is destroyed, the hair itself is readily 
extracted. The dexterity acquired by practice is requisite for 
the proper performance of the operation, with a view particu- 
larly to the insertion of the needle at the proper angle into the 
follicle. Few patients complain of pain. The number of hairs 
removed at a sitting varies with the sensitiveness of the patient's 
skin. The resulting scar is much less disfiguring than the hir- 
suties, suggesting the appearance of the male beard after shaving. 
Transitory maculae, papules, pustules, and wheals occur at the 
site of puncture. Care should be taken not to insert the needle 
too deeply in the particularly vascular regions of the face, as an 
aneurismal tumor might be produced as a consequence. 

A special instrument for the removal of superfluous hairs has 
been devised by Duhring. 1 It is of the shape of a thin lead- 
pencil or penholder, and is about four inches in length. The 
handle or stem is of hard rubber, through which passes a metal- 
lic rod, acting as a conductor for the transmission of the current. 

1 Arner. Jour, of the Med. Sci., July, 1881, p. 142. 



350 DISEASES OF THE BKIN. 

The needle is inserted into the needle-holder proper, which is 
slotted, the needle being clamped immovably by means of a 
Bcrew nut. On the other end of the stem, there is an insulated 
inserting-pin attached to the curd leading to the battery. The 
instrument is of proper weight, convenient to handle, and alto- 
gether well adapted for the operation. 1 

Hairy nsevi are best removed by complete, excision. 

Depilatories for the removal of superfluous hairs operate by 
the destruction of the filament without obliteration of the 
papilla. The consequence is that the hairs are reproduced in 
the course of about a fortnight. Most of the compounds used 
lor this purpose contain either the sulphate of calcium, sulphate 
of arsenic, or sulphate of barium, made into a species of paste 
with hot water. This is applied over the surface with a spatula, 
and permitted to remain till it dries, a period usually requiring 
ten minutes. It is then rapidly removed by scraping with the 
spatula, and the surface thoroughly cleansed with warm water, 
after which it is anointed with cold cream, or other similar 
unguent. 

Of these depilatories Duhring recommends the following: — 

R. Barii sulphis. 5'j ; 8 

Pulv. oxid. zinc, ) -- „••• . 10 

Pulv. amyl., $ aa 3llJ ' l4 M. 

The following are formulae devised by French authors: — ■ 

R. Sodii sulphat. Siij ; 12] 

? lci r' , I aa 3 x; 40! Ar 

Amyh pulv., ) J ' M. 

To be finely triturated, and, when used, to be made into a thiu paste 
with water. (Boudet.) 

R. Calcis 5j ; 41 

Sodii carbon. 5J SS ; ,; 

Cerat. adipis .^j ; 321 M. 

To be applied as a depilatory in the manner of a paste. 

All of these require caution in their use, and should never be 
intrusted to unprofessional hands. 

Shaving may be practiced upon the hirsute face of the female, 
and, with a similar end in view, epilation also; the latter, par- 
ticularly in cases of hypertrophy of the hair, limited in extent. 
Partial success has attended the thrusting into the follicles of 
needles, previously dipped in various caustic solutions, or heated 
in various degrees. 

1 The battery and needle-holder employed by the author in this operation, 
■were constructed for him by Messrs. A. M. Leslie & Co., of St. Louis: the 
admirable working of the apparatus having been demonstrated by him to a num- 
ber of physicians. 



HYPERTROPHY OF THE NAIL. 351 



Class V.— OF THE NAILS. 

Hypertrophy of the Nail. 

Hypertrophy of the nails is declared by an abnormal development of these 
appendages of the skin in any diameter. 

Symptomatology. — The nail substance may be developed to an 
unusual extent either as an idiopathic or symptomatic affection, 
and in either case may be either simply increased in volume or 
extent, or exhibit such increase in connection with secondary 
changes. Thus the nail may develop to an extraordinary length 
or breadth, preserving its general character as regards texture, 
color, and position ; or it may also be changed in either par- 
ticular, becoming opaque, discolored, and blackish or brownish ; 
rugous, furrowed, horny, and ridged ; thickened in one part and 
thin, vitreous and extremely fragile in another; tilted to one 
side or another on its bed ; or projected backward in recurved, 
irregular lines; finally the matrix may be inflamed, suppura- 
ting, hsemorrhagic, and the seat of an excruciating pain. One 
or more of the nails may be affected ; in some cases the entire 
twenty are similarly involved. 

The diseases in which these changes occur as symptomatic 
lesions are numerous, since it is evident that the matrix, from 
which the nail is produced, would scarcely enjoy immunity in 
the case of a profound alteration of the skin in its vicinage. 
Thus eczema, lepra, psoriasis, lichen ruber, syphilis, scarlatina, 
variola, and other diseases are attended by changes of various 
grades of severity in both matrix and nail. 

The condition termed paronychia, is that in which one or both 
lateral borders of the nail bury themselves deeply in the tissues 
adjacent, producing thus an exquisitely tender and painful state 
of the soft parts, which may suppurate or surround the attached 
limb of the nail with exuberant granulations. This is more 
frequently observed in the nails of the toes, as these appendages 
of the skin are liable to injury from the pressure of ill-fitting 
boots, gaiters, and shoes. In the condition described as onychia, 
the matrix is not only inflamed, but the nail substance is, as a 
consequence, texturally changed. No strict line of demarcation, 
however, can be described between the two conditions. The 
term onychogryphosis, has been employed to describe the con- 
torted deformities which cause it to resemble a claw. 

Onychomycosis is the name given to that condition in which 
the nail substance is invaded by vegetable parasites. In such 
cases, the nails become opaque, discolored, and thickened, with a 
noticeable friability at the projecting border. 



3-32 DISEASES OF THE SKIN. 

In SYPHILITICA onychia, one or Beveral of the nail- may be- 
come affected, though it is quite characteristic of the disease to 
exhibit limitation to the extremity of a single digit. In Buch 
cases, there is usually a very marked involvement <>t' the periph- 
eral soft part8,which may be infill rated with gummatous material. 
The bullous syphiloderra, of the congenital manifestations of the 
disease, will at times form beneath or quite near the nail, and 
thus endanger its integrity. In both forms, ulcerative results are 
common, with secretion of a hail discharge. 

The prognosis in these disorders of the nails, rests entirely 
upon the nature of the malady in which they occur. Idiopathic 
and localized changes, as also those occurring in transient cuta- 
neous diseases (r.. g. the exanthemata) often terminate favorably. 
In severe constitutional or grave cutaneous diseases, the outlook 
is less promising. The diseases of the nail are usually more 
obstinate and less amenable to treatment than the similar affec- 
tions of the softer parts. In cases where there is congenital 
disease of the nails, a prognosis should he given with reserve. 

Treatment. — The treatment of the disorders of the nail de- 
scribed above, is largely that of the maladies in which they 
occur. Arsenic and iron are often indicated in these affections; 
and their influence upon the nutrition of the nail cannot be 
questioned. In syphilitic onychia, the constitutional treatment 
of the disease is essential. The cutting, scraping and trimming 
of the nail by the aid of the useful instruments found in the 
chiropodist's case, supplied by most surgical instrument-makers, 
are important' measures in many cases. 

The treatment of in-growing toe-nail varies with the extent 
of the disease. In mild cases, soft threads of charpie are insin- 
uated between the offending border of the nail and the tender 
granulating surface upon which it presses. Counter pressure by 
plaster and the local use of the crayon of nitrate of silver, may 
be at times employed with advantage. In severer cases, the nail 
may be removed, though this is generally unwise. The method 
of treatment devised by Agard, of California, often produces 
the speediest results. The soft parts are by him completely re- 
moved from the side of the nail by means of a thin-bladed bis- 
toury; and the nail permitted to grow down upon one side of 
the extremity of the distal phalanx, thus protecting the cicatrix 
and radically preventing the recurrence of the disease. 

Atrophy of the Nail. 

This is a congenital or acquired condition, in which there is 
deficient or defective production of the nail substance. The 
congenital forms are usually observed when the digits are poorly 
developed, and there is at the same time a deficiency of the 
pilary growth. In the acquired forms, the causes and symptoms 
are often those of hypertrophy, the nail substance undergoing 



CUTANEOUS HEMORRHAGES. 358 

changes in color, bulk, elasticity, firmness, form, and position, 
having the general characters described above. Thus the nails 
may be seen to be expanded and thinned, narrow and acuminate, 
friable, laminated, furrowed, ridged and distorted. An excellent 
illustration of localized symptomatic atrophy of the nail, can be 
distinguished after convalescence from such wasting diseases as 
enteric fever, in which the deficient nutrition of the nail during 
the febrile period, is declared in smooth or rugous transverse 
furrows in its substance. 

The condition recognized as hypertrophy, is often a mere sta- 
dium of the process which results in remediless atrophy; and 
thus after many cutaneous affections accompanied at one period 
by enlargement or abnormal development of the nail substance, 
an atrophic condition may be the final result. 



Class VI.— OF THE BLOOD- AND LYMPH-VESSELS AND PERI - 
VASCULAR TISSUES. 

1. Hemorrhagic. 

Cutaneous Hemorrhages. 

Cutaneous hemorrhage is characterized by the issue of a part or all of the con- 
stituents of the blood from the cutaneous or subcutaneous capillary vessels, 
with and without rupture of the vascular walls. 

Hemorrhage into the skin may be active or passive, idiopathic 
or symptomatic, and may vary greatly in extent. It may be 
limited to but a small area of the integument; or be symmet- 
rical and universal ; or coexist with similar blood extravasations 
in the mucous membranes, and the investments and parenchyma 
of the viscera. It may result from undue intra-vascular pressure, 
as in violent effort with extraordinary demand upon the circu- 
latory system. It may occur with a normal intra-vascular pres- 
sure when there is lessened extra-vascular atmospheric pressure, 
as after ordinary exertion in high altitudes. It may result from 
disease of the vascular walls, as in malnutrition. It may occur 
after traumatism of the latter; or by diapedesis through the 
walls of uninjured capillaries. It may result also from lack 
of support of the vessels due to various disorders of peri- vascular 
tissues, as in the cases where the epidermis is artificially removed ; 
or where an abscess cavity is evacuated of pus and the sac im- 
mediately fills with blood. 

Idiopathic hemorrhage into the skin and neighboring tissue, 

is usually the result of traumatism, and accomplished through 

rent of the vascular wall. The discolored patches which result 

from contusions of the surface of the body, are illustrations of 

23 



854 DISEASES OF THE SKIN'. 

ibis condition. Examples of symptomatic cutaneous hemor- 
rhage*, are to l>e found in the course of Buch general disease 
septicaemia and variola, and of such cutaneous disorders as 
herpes, pemphigus, and erythema multiforme. 

Bulla b.bmorrhagice Hre globoid, bean- to egg-sized eleva- 
tions of the epidermis, filled with a sanguineous or sero-sanguin- 
eous fluid, giving such lesions a reddish, brownish, or purplish 
ghade. 

Ecchymomata are nut- to egg-sized and even larger, firm or 
fluctuating, flattened or elevated tumors, tilled with blood and 
having a cutaneous envelope. 

ECCHYM08ES are small coin- topalm-sized and even larger, light- 
red to dark purplish, irregularly shaped, macular colorations of 
the skin, not fading under pressure, and due to circumscribed 
cutaneous hemorrhage. 

Petechia are pin point to small coin sized, light-red to dark- 
purplish macular colorations of the skin, not lading under pres- 
sure, and due to circumscribed cutaneous hemorrhage. 

Purpura Hemorrhagica (Morbus maculosus Werlhoffii). 

This disorder, called also land scurvy, is usually ushered in 
with phenomena of a febrile character, accompanied by symp- 
toms of genera] depression. Subsequently, ecchymoses appear 
upon the extremities and trunk, both spontaneously and at 
points where the integument has been specially subjected to 
pressure and friction. Usually petechias appear simultaneously 
upon the nasal, laryngeal, buccal and other mucous surfaces, 
which may also be the seat of exhausting hemorrhages resulting 
rarely in fatal collapse. A symptomatic fever is usually awak- 
ened. The disease occurs equally in the robust and feeble of all 
ages, and though usually as a sporadic affection, it may assume 
an epidemic form. The disease is slow in its course, but com- 
monly terminates favorably after the lapse of several months. 

It is distinguished from purpura scorbutica, or "scurvy," by 
the distinctive premonitory symptoms of the latter disease, and 
its invariable occurrence among those suffering from improper 
alimentation, vitiated air, and lack of exercise. 

Purpura Pulicosa 
is the result of the traumatisms produced by fleas, lice, and 
bugs. The lesions are puncti form, and due to the welling up of 
blood into the minute punctured wound, surrounded usually by 
an hyperaemic halo, which is the result of the irritation. When 
the latter fades, the central hemorrhagic point, usually for a 



CUTANEOUS HEMORRHAGES. 355 

brief time persists. The disease is characteristically manifested 
upon the filthy skins of individuals long bitten by bugs, and 
covered with excoriations and dark-colored crusts, the result of 
scratching. I have known several such cases to be pronounced, 
scorbutic. 

Purpura Rheumatica (Peliosis Rheumatica). 

This is a variety of purpura which has a striking analogy to 
erythema multiforme, and is probably an exaggerated form of 
some of the conditions recognized under that title. It is pre- 
ceded by the usual febrile or other premonitory symptoms asso- 
ciated with arthritic pains, especially of the knees and ankles, 
which may become swollen, or be affected with an hydrarthrosis. 
In a few days, petechial to ecchymotic, light-red to dark-purplish 
maculations appear upon the extremities, trunk, or the entire 
surface of the body, fadeless under pressure, and usually with 
coincident relief of the arthritic pain. The subjective sensations 
are ordinarily trivial. In a fortnight, the eruption may subside, 
its color undergoing the usual variations from greenisb to orange 
and light yellow ; but relapses are common in the course of 
weeks, with recrudescence of the fever, return of the rheumatoid 
symptoms, and progressive asthenia. Kaposi describes cases in 
which there was coincidence of purpura rheumatica with renal 
hemorrhage, albuminuria and gangrene of the soft palate, in 
consequence of its over-distension with blood. Cases are also on 
record where there was cardiac involvement and grave disorder 
of other viscera. According to Mackenzie, 1 the disease occurs 
in both sexes, more frequently in women, however, and between 
the ages of twenty and thirty, though also at earlier periods of 
life. The purpuric spots observed by him usually made their 
appearance regularly in the afternoon or evening, sometimes 
daily, and often with several days' interval, accompanied by 
pain, stiffness, and swelling of the joints. The maculae w r ere at 
first of a bright reddish hue, but became purplish by the ensuing 
day. The site of predilection was the extremities, but the erup- 
tion in his cases was sometimes more generalized. 

The lesions displayed this amount of symmetry; if they oc- 
curred on one extremity, upper or lower, they would generally 
be found on the other. As a rule, there were not profuse sweats, 
unless the attack occurred with rheumatic fever ; the joint affec- 
tions and pyrexia, though distinct, were not severe. Sometimes 
there was a certain amount of erythema accompanying the 
hemorrhages; often the eruption was purely hemorrhagic. The 
attacks were frequently very protracted, lasting even some 
months, and w r ere liable to recur. 

The disease occurs in both sexes, though more often in young 
women, and is to a certain extent influenced by the changes of 

1 Brit. Med. Jour., March 18, 1882, p. 383. 



356 DISEASES OF THE SKIX. 

climate and Beason. Ita diagnosis, in consequence of its marked 
characteristics, coincidence of petechia? and ecchymoses with 
rheumatoid pains, is readily effected. Duhring calls attention 
to tin- danger of confounding it with the macular sypihiloderm, 
the lesions of which, however, fade under pressure. The prog- 
nosis i> in general favorable, though the disease may persist for 
long periods of time, and may, in rare cases, terminate fatally. 

Purpura Scorbutica (Scurvy). 

This disorder is peculiar to those who are compelled to subsist 
for lengthened periods of time on improper food, more particu- 
larly that from which fruit and fresh vegetables are excluded ; 
to respire a vitiated air; and to endure such confinement as pre- 
cludes the possibility of duly exercising the body. The disorder 
is hence more common among sailors, prisoners, Arctic voyagers, 
and men similarly situated. 

The hemorrhages which result are quite like those of purpura 
hemorrhagica ; and the cutaneous lesions are petechias, ecehy- 
moses,and painful ecchymomata, which may fluctuate, open, and 
result in offensive ulcerations reaching to the bone. Simulta- 
neously with the cutaneous eruption, the gums become involved, 
and show as tumid, hemorrhagic, or ulcerative fungosities, 
smeared with a dirty -yellowish secretion, and having a fetid ex- 
halation. The subcutaneous connective tissue, muscles, fasciae, 
and viscera, become also involved. The disease is accompanied 
by febrile and other general phenomena of asthenia, and, when 
the causes are persistent, results fatally. It is, however, reme- 
diable by proper treatment, though convalescence is usually 
tediously prolonged. 

Purpura Simplex. 
In this form of cutaneous hemorrhage, light red to dark 
purple petechias and small ecchymoses, usually multiple and 
symmetrical, of slow or sudden occurrence, appear upon various 
portions of the surface, chiefly over the lower extremities; and 
here doubtless by preference, because of the greater effect of 
gravity upon the column of blood. They usually awaken no 
subjective sensation, and may occur in persons of apparently un- 
altered health, though rigid examination will often disclose 
some facts having a bearing upon the etiology of the disease. 
The subjects of the disorder are frequently asthenic, and complain 
of unwonted lassitude and malaise. The disease may last for 
a fortnight, and in exceptional cases is accompanied by a febrile 
rise of temperature. 

Purpura Urticans 
is that form in which there is an irritability of the skin sufficient 
to produce wheals, urticarial lesions accompanied by itching in 



CUTANEOUS HEMORRHAGES. 357 

various degrees, which have the purpuric hue iti consequence of 
circumscribed cutaneous hemorrhage. 

Vibices are linear maculations of various lengths, due to the 
diffusion in the skin of extravasated blood in the form of streaks 
or bands. They are often commingled with petechias and ec- 
cbymoses. 



Tlie symptoms of cutaneous hemorrhage are also observed in 
other conditions besides those named above. Thus a form of 
purpura medicamentosa has been produced by the ingestion of 
the compounds of iodine, tar, and chloral. Petechia and ecchy- 
moses are also in cases noted upon the lower extremities of the 
subjects of tuberculosis, cancer, and the plague. In Haemophilia, 
a disease occasionally of hereditary origin, and characterized by 
the facility with which trivial traumatisms of the surface are 
followed by incoercible hemorrhages, purpura may be the first 
signal of the predisposition. A young man with purpuric lesions 
of both lower extremities and otherwise in apparently good 
health, lately presented himself at my clinic for the relief of the 
difficulty. There was at the time no suspicion of haemophilia, 
but two weeks later, as the result of a vaccination, he bled con- 
tinuously for eight days. 



Pathology. — Many cutaneous hemorrhages, not resulting from 
traumatism, however manifestly and immediately due to morbid 
conditions of the vessels, are by many authors believed to have 
a neurotic origin. Purpura basmorrhagica, for example, is by 
Wagner, Henoch, and others explained by either abnormal ex- 
citation of the sympathetic system, or paresis of the vaso-motor 
centres, in consequence of the frequent absence of lesions of the 
vascular walls sufficient to explain the phenomena. Cavalier 1 
reports a case of purpura alternating with paralytic symptoms. 
The frequent symmetrical disposition of the lesions has received 
a similar interpretation. Tyrrell 2 reports cases induced by 
marsh-miasm ; and lately Satterth waite, 3 of jSTew York, a similar 
case in which the eruption followed a chill lasting three-quarters 
of an hour. 

The hemorrhages occur in all these cases, chiefly in the derma, 
though often in the subcutaneous connective tissue, a fact well 
illustrated in the drawings made "by Variot, 4 of sections of the 
purpuric skin of a patient dead of haemoptysis. In this case 
there was numerical diminution of the red blood-corpuscles in 

1 Bull. Gen. de Therap., 1879. 

2 Pacific Med. and Surg. Journ., June, 1876, cited by Duhring. 

3 Med. Gazette, Jan. 14, 1882, p. 14. 

4 Jour. d. l'Anatom. et de la Phys., No. 6, Nov.-Dec. 1881, p. 520. 



358 DISEA8E8 OF THK SKIN. 

life, iis demonstrated by tlie hemati metre, without any change 
in their form, volume, or color, [nflammatory complications in 
these conditions arc rare. The color of the several lesions in- 
duced is, without question, derived from the hsematine, which 

not only stains the environing fluids, hut also the tissues them- 
selves where the extravasation occurs, and appears, when absorp- 
tion of the fluid portions of the clot has been accomplished, in 
the form of variously sized crannies. In this way the color- 
changes between red, orange, yellow, purple, and violet in the 
resolution of petechia' and ecchymoses are to he explained. The 
persistence of their pigmentations varies with the quantity of 
the effused blood and its seat. In mild cases, especially of 
lesions involving the upper half of the body, all traces of the 
hemorrhage may be removed in the course of a few weeks. I 
have seen dark pigmentations resulting from purpura scorbutica 
affecting prisoners at Andersonville during the late civil war 
in this country, which are still perceptible upon the lower ex- 
tremities. 

Treatment. — The treatment of these various forms of cutaneous 
hemorrhage will clearly depend upon the nature of the cause in 
each case. In general it may he said that internally the use of 
ergot, of the perchloride or other salt of iron, and of quinine is 
advisable. Hypodermic injections of Bonjean's ergotine, one 
part to two of distilled water, repeated every second day have 
been speedily followed by favorable results. A generous diet, 
the use of wines, malt liquors, and even spirits, and strict ob- 
servance of the demands of hygiene, are often essential methods 
of relief. 

In the way of local treatment, rest in the recumbent position 
is advisable, and, if hemorrhage be actually in progress, the free 
use of haemostatics will he required with local application of ice. 
For those who are convalescent from systemic disorders ac- 
companied by purpuric lesions of the lower extremities, re- 
sorption of the extravasated blood may be hastened by stimu- 
lating spirit lotions with friction; and the pressure of the blood 
column partly relieved by elastic bandaging of the extremities. 

The prognosis lias been given, as far as might he, in connec- 
tion with each disorder named. 

2. Neoplastic. 

Angioma. 

DeriV. Gr. iyy^ov, Vessel. 

Angioma is that pathological development which is constituted wholly or in 

part of dilated or new-formed blood- or lymph-vessels. 

The angiomata are naturally divided into those composed of 
bloodvessels and those formed of lymphatic vessels. The former 
are much more frequent and variable in character. 



ANGIOMA. 359 

Blood-vascular new-growths occur in three forms: nsevus 
vasculosus, telangiectasis, and angioma cavernosum. 

Naevus Vasculosus. 

This term is limited to those vascular anomalies of the skin, 
which are either visible at birth or become developed within a 
brief period thereafter. They commonly occur as irregularly 
outlined or distinctly circumscribed, smooth spots, patches, or 
maculations, varying in color from "light red to deep violet and 
port-wine, either flat or very slightly elevated above the gene- 
ral level of the integument. From this type wide variations are 
noted, from the development of pea-sized papules, or tubercles, 
to tumors even of large size; pulsating and. aneurismal in char- 
acter; spongy or relatively firm; fading or more rarely persist- 
ent underpressure; superficial or deeply seated; venous or arte- 
rial in their connections; single or numerous; and in either case 
limited to a small area or involving a relatively large surface. 
They are of most common occurrence upon the head, but are 
seen also on the trunk and extremities. Often they are the sole 
lesions of the skin present in a single individual; in other rarer 
cases they complicate moles, warts, and lymphangiomata. 

The course of these lesions varies with their essential charac- 
ter. Of the simpler varieties, the larger number increase some- 
what in extent and development till they have attained a maxi- 
mum size, and then either persist indefinitely or accomplish a 
species of involution after agglutination of the vascular walls, 
leaving a whitish, cicatriform, occasionally pigmented surface. 
Others extend indefinitely, involving the neighboring mucous 
surfaces, subcutaneous tissue, and deeper structures, forming vast 
tumors, destructive not only by their tendency to extension, but 
by their mechanical effects. Fortunately these extreme devel- 
opments are rare. Much more commonly they are observed in 
the form known as the "port-wine mark" or " claret-stain," 
which awaken no subjective sensations, and are usually of clini- 
cal importance in consequence of the marked disfigurement 
which they occasion. 

Telangiectasis. 

Telangiectases are acquired blood-vascular new formations, 
which appear at periods of life other than at birth or a few 
months later; and are, therefore, distinct from the congenital 
forms of the disease. They are commonly first observed in 
adult life, and occasionally multiply with advancing years. 
They occur in diffuse and localized forms. 

Diffuse, generalized telangiectasis is exceedingly rare. Hil- 
liaret and Vidal have each observed one such case in individuals 
of both sexes; the condition being apparently due to systemic 
disturbance. 



300 DISEASES OF THE SKIN. 

The localized tonus are betrayed by the occurrence of flat or 
slightly elevated, pin-head to pea-sized maculae; diffuse patches; 
linear ramifications of individual vessels ; or contorted cqngeries 
of a plexus of the latter, all exhibiting the variations in'color 
of lwevi vasculosi, hut usually of pinkish or violaceous hue. 
They are unaccompanied by Biibjective sensations, are evidently 
non-inflammatory in character, and are seen as single or multiple 
lesions chiefly upon the face, but also upon the neck, the hacks 
of the hands, the thighs, and other parts of the body. They 
are not rarely observed in connection with other diseases. Thus 
they occur in the vicinity of lupus erythematosus, morpboea, 
acne rosace;,, cicatrice*, and about the contour, or over the sur- 
face of many malignant tumors. Thus they may have either 
an idiopathic or symptomatic character. 

The term rosacea, as distinguished from acne rosacea, is em- 
ployed by some authors to designate that condition in which 
the skin, of the face particularly, exhibits a circumscribed or 
diffuse redness, due to dilatation of the capillaries, unassoeiated 
with acne or other sebaceous gland disorder. 



Angioma Cavernosum 

is distinguished from the lesions described ahove by the pecu- 
liarities of its formation. It consists of a dense frame-work of 
new-formed connective tissue, inclosing loculi or chamhers of 
varying capacity containing blood, and communicating not only 
with each other but with the larger vessels in the" vicinity. 
Whether they originate in the fibrous felt-work of the derma, 
which later establishes a vascular connection ; or in the vessels 
themselves; or are constituted by a mechanical dilatation of 
the latter in consequence of new-formed connective tissue in the 
adventitia, has not been determined. 

Etiology and Pathology. — The causes of the several pathologi- 
cal conditions named ahove are obscure. The symptomatic 
telangiectases are undoubtedly to be explained by obstruction 

to the circulation occasioned by the tumor or other lesions to 
which they are accessory. The foundation for the vulgar belief 
that maternal impressions are responsible for the "so-called 
"mother's marks" is very slight. The reputed resemblance of 
the latter to various flowers and fruits, generally requires for its 
recognition a stretch of the imagination. 

Anatomically, these lesions are recognized as due to dilatation 
and formation of venous and arterial capillaries in the superior 
portions of the derma, the vessels of the newly formed plexus 
freely communicating with each other. Generally there is a 
simultaneous new formation of connective tissue constituting 
the frame-work of the growth, which varies considerably in the 
different forms of the disease. Lobules constituted of/coils of 



ANGIOMA. 361 

capillary vessels are often separated by it into distinct masses. 
According to Heitzmann, the large spaces of angioma cavernosum 
imitate the structure of the corpora cavernosa of the penis, and 
are filled with venous blood, being separated from each other by 
a scanty fibrous connective tissue. 

Treatment. — The treatment of telangiectasis and nasvus is the 
same; and is limited to a series of local surgical procedures. 
These all have in view either the destruction of the new growth, 
or the artificial production of an inflammation in order to ob- 
literate the lumen of the capillaries of which it is composed, to 
an extent sufficient to interfere with the transmission of the 
blood-current. 

First among these is electrolysis. One or a set of several fine 
cambric needles with their points at the same plane, are connected 
with the negative pole of an ordinary zinc and carbon battery 
of ten to twelve cells. The points of the needles are quickly 
passed into the tissues and there held for a period of between 
ten to thirty seconds, according to the effect produced after 
completion of the circuit. The new growth is thus blanched 
in the vicinity of the needles, this effect disappearing in the 
course of a few moments. In about three weeks, the curative 
result of the operation becomes apparent. According to Fox, 1 
of New York, who has offered the latest contribution to this 
subject, the objections are that the operation is sometimes pain- 
ful and tedious, and may occasionally result in the production 
of suppuration, superficial sloughs, minute, keloid-like eleva- 
tions, vascular nodules, depressed scars, or superficial ulcers. 

The method of Sherwell 2 is by multiple puncture with a set 
of fine needles in a holder similar to that described above. 
These are dipped in a twenty-five to fifty per cent, solution of 
chromic acid, and then made to penetrate the part to be attacked. 
The bleeding is readily arrested by pressure ; and then the patch 
is to be covered with several superimposed layers of flexible col- 
lodion. I regard this procedure as of value in circumscribed 
patches of superficial character and relatively limited area. By 
it, I have succeeded in removing port- wine marks in three pa- 
tients, with the result of producing a somewhat irregular cica- 
triform tissue much less disfiguring than the original blemish. 
One of these patients was repeatedly exhibited at the clinic 
during the progress of the case. 

Squire's operation is done upon previously frozen patches, by 
the aid of an instrument which destroys the vessels by making 
numerous crossed and closely spaced linear incisions, parallel to 
each other and in a plane obliquely directed to that of the integ- 
ument. Here also bleeding is arrested by pressure, exerted before 
the circulation is restored. The operation has been, in hands 
other than his own, attended at times with unsatisfactory results. 

1 New York Med. Rec, Feb. 18, 1882, p. 188. 

2 Archives of Derm., Oct. 1879. 



362 DISEASES OF THE SKIN. 

Sodium ethylate, a compound in which the radical ethyl in 
ethylic alcohol is united with sodium, is a caustic recommended 
by Richardson, 1 in the treatment of nsevus. It is applied by 
means of a glass rod. A first application usually results in the 
formation of a dense crust under which the mcvus contracts; 
and repeated applications are made at intervals of a few days 
till the desired result is obtained. The sodium ethylate should 
be pure, and the crusts should not be disturbed till they fall 
spontaneously. In one ease observed by myself, there was a 
persistent redness of the resulting sear which was decidedly 
open to objection. 

Other methods employed are the ligature when practicable; 
puncture with hot needles; the topical application of caustics 
other than those named above, such as potash, nitric and carbolic 
acids and corrosive sublimate; and total excision, the latter be- 
ing practicable in relatively small growths. The galvano-cautery 
and the thermo -cautery are both valuable in the destruction of 
the capillaries, and have repeatedly proved successful in my 
hands. For telangiectases and nsevi no larger than a pea, I regard 
the Paquelin knife as the most efficient resort. The old method 
of multiple vaccination about and upon the involved area, is 
frequently followed by the best of results; and whether in con- 
sequence of the retraction of tissue under the influence of the 
inflammation excited, or of the destructive results of the sup- 
puration induced, or of an indefinite caustic effect is not, as 
Kaposi suggests, quite clear. 

These results may be {tartly imitated by the induction of su- 
perficial pustulation and suppuration through the medium of 
tartar emetic and croton oil, methods which certainly should be 
considered clumsy in the light of recent successes, obtained by 
more manageable expedients. In that light certainly, all injec- 
tions of angiomatous growths should be condemned. 

Combs- has lately modified somewhat the method most in 
vogue, by passing fine silver wires through nrevous growths, and 
connecting the extremities with a Bunseu's battery. When the 
wires are heated, the circuit is broken, and the ends of the wires 
disconnected from the battery and united to each other, being 
then left in situ and covered with lint and plaster. The current 
can then be passed repeatedly without reinsertion of the needles, 
and the latter need be withdrawn only when the cure is complete. 

The treatment of angioma cavernosum manifestly requires 
surgical interference. 

The prognosis in any case of angioma will evidently rest upon 
the method of treatment adopted for its removal. In the larger 
number of cases, the lesions having attained a maximum devel- 
opment, persist without further pathological change, constituting 

1 Lancet, Nov. 9, 1878. 2 London Lancet, 1881. 



LYMPHANGIOMA CUTIS. 363 

a deformity rather than a disease. Physiological alterations in 
the color of such lesions, occur under the influence of changes in 
the circulation. 



Lymphangioma Cutis. 

New growths of lymphatic vessels in the skin have heen noted 
as constituting a cutaneous disease proper, only by Hebra and 
Kaposi, Pospelow, 1 and Van Harlingen. 2 By the authors first 
named the disease is termed Lymphangioma tuberosum multi- 
plex. The lesions in these several cases were multiple, pea- to 
bean-sized, smooth, roundish, reddish lilac-tinted or bluish, firm 
or compressible tubercles, implanted in the skin, and occurring 
first in early life, about the neck and trunk. Some of these 
were quite reducible under pressure, and transparent. In Van 
Harlingen's case, the lesions were destitute of fluid contents and 
also interspersed between telangiectases. Anatomically, round- 
ish or oval spaces appeared in sections, recognizable as distended 
lymphatic vessels by the characteristic endothelium with which 
they were lined. Kaposi distinguishes these tubercles from all 
subcutaneous cavernous tumors constituted of new-formed di- 
lated lymphatic vessels reaching toward the skin, by the limita- 
tion in the former of the neoplastic growth to the superior parts 
of the corium. 

In comparing these with the large number of cases of con- 
genital and acquired dilatation of the lymph channels, collated 
in the valuable monographs on these subjects hy Dr. S. C. Busey, 3 
of Washington, D. C, a further special difference between the 
two becomes apparent. In the latter, when the lymph-filled 
vesicle, papule or tubercle, which appears upon the integument 
is ruptured, there at once supervenes an exhausting drain from 
the bodj% of pure coagulable lymph, a feature which is not 
described by the dermatological authors named, as of occurrence 
in their cases. 

' Viertelj f. Derm. u. Sypb., Hft. 4, 1879. 

2 Paper read before tbe Am. Derm. Ass., Sept. 1881, Pbil. Med. Times, Sept. 
24, 1881. 

3 Congenital Occlusion and Dilatation of tbe Lymph Channels (Amer. Journ. 
of Obstet., Jan. 1877, etseq.}; Narrowing, Occlusion, and Dilatation of Lymph 
Channels, Acquired Forms (New Orleans Med. and Surg. Journ. No. 3, 1876, 
to No. 8, 1878, inclusive). See, e. g., history of Berkley Hill's patient, p. 101 ; 
of Zambuco's, p. 120; of Carter's, p. 103; of Cholmley's, p. 136; of Jackson's, 
p. 173, and many others. 



3G4 DISEASES OF THE SKIN. 

Class VII.— OF THE NERVES. 

I. Anomalies of Sensation. 

Pruritus. 

Deriv. Lat. prurire, to itch. 

Pruritus is a functional disorder of the skin, characterized by the sensation of 
itching in a part or a whole of the body, unaccompanied by objective symp- 
toms of disease, and evoked primarily by no exterior cause. 

Symptomatology. — Pruritus is to be distinguished not only 
from prurigo, a rare disease of the skin already described, but 
also from the symptomatic sensation of itching which is occa- 
sioned by a number of cutaneous disorders, such as eczema, 
scabies, and those produced by pediculi. Hebra was first to 
recognize the independent character of the disease here con- 
sidered ; and it is perhaps to be regretted that he did not give 
to it a name distinct from that which is also applied to a symp- 
tom common to several maladies of the skin. 

Pruritus is characterized by a sensation of itching not pro- 
duced originally by cutaneous lesions, or by exterior causes. It 
may he general or partial. In either form, it begins usually by 
a tickling, pricking, crawling or itching sensation in the skin, 
which solicits the sufferer to rub, press, scratch, or otherwise 
irritate the affected integument. It usually occurs by accesses 
in the day or night, much more often the latter, occasionally 
both; and these accesses manifestly occur under the immediate 
stimulus of some internal or external cause. Thus moral emo- 
tions, a cool draught of air, the warmth of the bed, the pressure 
of clothing, and often the substances applied externally with a 
view to the relief of the pruritus, suffice to determine a crisis. 
However firmly the sufferer may determine to avoid injury to 
the person, in well-marked cases the impulse to scratch becomes 
well nigh irresistible, and, in the highest degree, tormenting. 
From the milder, the patient will thus be frequently teased to 
inflict the severer injuries upon the skin. Brushes, combs, coarse 
cloths, and even metal instruments, will be employed in exagge- 
rated cases, for the purpose of assuaging temporarily the local 
distress. 

The objective cutaneous symptoms which may be presented 
are all secondary, and invariably result from self-inflicted injury. 
In some cases they do not appear, the statements of the patient 
being the sole basis for a recognition of his disease. This may 
be the consequence of unwonted self-control, or of the mildness 
of the malady, or of the transitory character of the lesions pro- 
duced. Thus the skin may be reddened during a nocturnal 
paroxysm under the manipulation of the sufferer, and the trail- 



PRURITUS. 365 

sitory hyperemia disappear in the daytime when the skin is 
submitted for inspection. Not rarely, however, the integument 
resents the treatment to which it is subjected, by displaying 
wheals, hypersemic blotches, reddened papules, excoriations, 
characteristic " scratch lines," and the minute blood-crusts which 
indicate that the papillary layer of the derma has been reached 
and slightly torn. As these are among the recognized causes 
of eczema and dermatitis, it is not surprising to note that such 
disorders of the skin may be in this way originated, and still 
further add to the subjective distress. 

The localized forms of pruritus, albeit the abnormal sensation 
is in them limited to certain regions of the body, may occasion 
fully as much distress as those in which a larger part of the in- 
tegument is affected. They are of more frequent occurrence 
than the generalized forms. Pruritus of the anus, of the scrotum, 
of the vulva, of the vagina, of the scalp, of the nose, of the 
mouth, of the axillae, are all localized forms of the disease, two 
or more of which may coexist or develop in succession. 

In all exaggerated forms of pruritus cutaneus, the general 
health perceptibly fails. Whether from prolonged insomnia 
arising from the nocturnal exacerbations to which there are but 
few exceptions; or from the perversion of nutrition incident to 
the continuous teasing of the nervous system; or yet from the 
hypochondriacal state into which some patients are plunged 
by their sufferings, such an issue is often to be expected. It is 
in fact a complication which may merit, as much as the disease 
itself, the attention of the physician. 

Etiology. — The causes of pruritus are numerous, and the neces- 
sity for the discovery of the particular cause in each patient, 
often makes the largest demands upon the practitioner. The 
disease may occur at all periods of life, and in both sexes, but 
its exaggerated forms are peculiar to middle life and advanced 
years (pruritus senilis). It is frequently a reflex symptom of 
one of several internal disorders. Among the latter may be 
named, malarial affections, disorders of the liver or kidneys, 
(especially jaundice, Bright's disease, and diabetes), and dis- 
turbances of the alimentary canal, including those due to intes- 
tinal worms, haemorrhoids, and dietetic or medicinal ingesta. 
It may be associated with almost every one of the functional, 
and not a few of the organic, disorders of the uterus and ovaries. 
The same may be said of its dependence upon the genito-urinary 
diseases of the male sex, including stone in the bladder, stricture 
of the urethra, disorders of the testis and epididymis, and per- 
verted sexual hygiene. 

Lastly, the moral emotions of a depressing character play an 
important part in the etiology of pruritus. Mental distress, oc- 
casioned by bereavement, separation from relatives, misfortune 
of all sorts, and anxieties as to the future, often find physical 
expression in the disease. 



366 DISEASES OF THE SKIN. 

Pathology. — The disease is essentially a functional disorder of 
the nerves of sensation supplied to the skin, and is of itself in- 
capable of producing objective Bymptoms. This fact can, in 

some eases, l>e eli ideally demonstrated, as the Beal of the pruritus, 
even though exhibiting nrtificially produced lesions, will, when 
protected from all external injury, speedily regain its normal 
appearauce, the pruritus no less continuing. It is probable, 
though not certain, that the nerves also in this disease undergo 
no structural change, hut merely convey to the periphery a per- 
verted sensation which is often reflected from some point of 
centric disturbance. 

Diagnosis. — The recognition of general pruritus is usually not 
difficult, as the secondary results of the disease are apt to be 
less marked than in its other forms. The complaint of the 
pat ieiit , the failure of cutaneous disease sufficient to explain his 
symptoms, and especially the discovery of such a sufficient cause 
in some visceral or systemic disorder, are all significant. It 
must lie admitted, however, that when the disease is localized 
and complicated, as it frequently is, by an eczema or dermatitis, 
obscurity often arises. Attention should then be paid to the 
history of the disorder, which may reveal the fact that the 
pruritus preceded for some time the cutaneous symptoms, and 
may reveal even more. Intelligent patients will often assure 
the physician of the real nature of their malady, by voluntarily 
remarking, that the skin symptoms disappear upon the region 
which is not scratched, though the pruritus continues. In all 
cases the operation of exterior agencies should be carefully 
eliminated. 

Prurigo, with its infiltrated skin, its primary papules, and its 
severe itching, beginning in early infancy and commonly per- 
sisting through life, can scarcely be confounded with pruritus 
cutaneus. 

Treatment. — The degree of success to be obtained in the treat- 
ment of pruritus cutaneus, is largely proportioned to the skill 
with which the cause of the disease is recognized and remedied. 
Taking into consideration the number of systemic and visceral 
disorders which may be, in different cases, responsible for the 
skin symptoms, it is clear that an exhaustive study of the mental 
and [physical history of each patient, will be essential at the onset 
of treatment. The cause once recognized, the treatment should 
be directed to the special disorder discovered ; and this largely 
requires the skill of the general practitioner. The gastrointes- 
tinal tract, the kidneys, the liver, the bladder, the uterus, the 
prostate gland, the rectum, and indeed any one of the viscera, 
may require therapeutic management. For the frequent gastric 
disorders, the alkalies and alkaline waters, with occasional ca- 
thartics and strict regulation of the diet, are often useful. At- 
tention should be particularly directed to any medication to 
which the patient may have been subjected with a view to a 



PRURITUS. 367 

therapeutic effect, and which may have aggravated the com- 
plaint. The mineral acids, chalybeates, pepsin, lactopeptin, 
quinine, strychnine, phosphorus, arsenic, or atropine may be 
indicated in individual cases and productive of favorable results. 

The substances which have been topically employed for the 
relief of pruritus cutaneus are almost without number, a fact 
warranting the conclusion that each occasionally fails to afford 
the desired relief. This is corroborated in every wide clinical 
experience; that preparation, moreover, which is at one time of 
the highest value, will disappoint at another period in the his- 
tory of a single case. Attempts to secure relief by such topical 
applications should, however, be always made, and will often 
be followed by gratifying results. 

First in order of value are baths and lotions of water, hot, 
warm, or cold, and medicated by the addition of the sodic 
bicarbonate or biborate, the potassic carbonate or sulphuret, 
varying in strength from one ounce (32.) of the last-named to 
six ounces (200.) of the first-named suhstance, in thirty gallons 
of water. Gelatine or bran may often with advantage be added 
to these, as suggested in the chapter on general therapeutics. 
Alcoholic, ethereal, camphorated, and carbolated lotions are to 
he regarded as of equal value. Du bring specially recommends 
solutions of carbolic acid, in the strength of from five to twenty 
grains (0.33-1.33) to the ounce (32.) of water, to which a half 
drachm (2.) of glycerine has been added. Robe similarly em- 
ploys boracic acid, one drachm (4.) to the pint (500.). 

Baths and lotions of this character usually procure merely 
temporary relief; and the treatment in the interval of their 
application demands the wearing of soft linen, or other unirri- 
tating material next the skin, and the free use of a dustino-. 
powder. Those of pure starch are here less useful than those 
compounded with oxide of zinc and bismuth, as in the "Ander- 
son powder." Gorecki 1 mingles the starch with perfectly pure 
boracic acid. 

Dr. B. W. Taylor, of JSTew York, in a valuable paper, 2 gives 
the following formulae : — 

$. Potass, sulphuret. 

Camphor, spts. 

Glycerin. 

Aq. font. q. s. ad 13 vj ; 200 M. 

S. For external use as a lotion, and to be applied by the medium of 
saturated strips of lint. 

I£. Spts. camphor. f §ss ; 16 

Boracis. 51 j ; 8 

Glycerin. f 31J ; 64 

Aq. fluv. |vj ; 200 M. 

S. To be well shaken and applied externally. 

! Le Praticien, Oct. 3, 1881, p. 473. 

2 On the Various Forms of Pruritus Cutaneus. and their Treatment, Arch 
of Clin. Surg. : Rutledge & Co., 1877. 



S"j ; 


12 


fgss; 


16 


*'?j; 


32 


q. s. ad f.^vj ; 


200 



368 DISEASES OF THE SKIN'. 

Morphia, in the Btrength of one grain (.066) to the ounce 
(32.), may be added to this and other lotions. 

Chloral-camphor, u pungent, syrupy liquid obtained, as BUg- 

1 by Bulkley, of New York, after triturating an equal 

amount of the two substances in tine powder, is an antipruritic 

remedy of value in certain cases when properly diluted, thus : — 



i:. 


Chloral-camphor. 


5 SS ; 


16 




Glycerin. 


»'5.i ; 


32 




A(|. ros. 


ad f.^viij ; 


250 


S. 


For external use. 







M. 

Other lotions may be made to contain corrosive sublimate, 
one-quarter of a grain (.016) to the ounce (32.); dilute hydro- 
cyanic acid, a drachm (4.) to the half pint (250.); Goulard's ex- 
tract, a drachm (4.) to the {tint (500.); chloroform; sulphur; 
alum; dilute nitric, aeetie, or salicylic acids ; tannin ; or the zine 
Bulphate in due proportions. 

Often the aqua calcis, medicated with calomel, zinc oxide, bis- 
muth, or calamine, answers well; and, if tolerated at all, the 
addition of linseed oil, four ounces (130.) to the pint (500.), 
with a drachm (4.) of one of the inert substances named, flavored 
with rosemary or bergamot, will aid in relieving the local 
distress. 

Ointments and fatty substances in general are usually not well 
tolerated in cutaneous pruritus. Occasionally, however, they 
are of more value than lotions, and may be made to contain one 
or more of the substances named above, such as carbolic acid, 
live grains (0.33) to the ounce (32.); subnitrate of bismuth, a 
scruple (1.33) to the ounce (32.); chloral-camphor, five minims 
(0.33) to the ounce (32.); and calomel, five to ten grains (0.33- 
0.66) to the ounce (32.) of cold cream, petroleum ointment, or 
lard. 

Tarry substances are usually not well tolerated in the disease, 
and are, as a rule, when the skin is sound, objectionable as liable 
to irritate. Duhring, however, speaks well of the liquor carbonis 
detergeus, in the strength of a drachm (4.) to two ounces (64.) 
of water. This alcoholic solution of coal tar has been for some 
time in the market of our large cities. Special attention has 
been directed by many writers to the treatment of the local 
forms of pruritus, the principles of which have been in the main 
described above. For pruritus of the vulva, Wiltshire 1 recom- 
mends decoctions of almond meal, marsh-mallow, slippery elm, 
and rice; and in case of failure of the latter, an infusion of 
tobacco, two ounces (64.) to the pint (500.). Vaginal injections 
of hot water and tampons or cocoa-butter suppositories medi- 
cated with opium, belladonna, or carbolic acid are also available. 

Many of the medicaments named above are also useful in 
pruritus of the ano-genital region. The application of very hot 

1 British Medical Journal, March 5, 1881, p. 328. 



PRURITUS. 369 

water is of decided service. Exception should be made here to 
the rule with regard to the exclusion of tars generally from the 
treatment of pruritus; as in the distressing itching of the scro- 
tum and anus especially, they are often essential. The tincture 
of tar, oil of cade, and oil of white birch will here often be 
needed. Pencilling any existing fissures with the compound 
tincture of benzoin or nitrate of silver, is serviceable. The 
scrotum when attacked, usually requires the use of a suspender 
or suspensory bag, lined with soft lint or borated cotton, which 
may also be incorporated with a dusting powder, wetted with a 
lotion, or smeared with an unguent. 

Simon has successfully employed pilocarpine in cutaneous 
pruritus, both internally and by hypodermic injection. For 
the latter, the muriate of pilocarpine is used in doses of one-sixth 
of a grain (0.011). The same author has administered with 
good results a syrup of jaborandi, made in the proportion of 
three parts of the leaves of the plant to fifteen of water and 
eighteen of dissolved white sugar, of which two tablespoonfuls 
are taken as a dose. 

Lastly, it should not be forgotten that many cases of intract- 
able pruritus are best managed when the attention of the patient 
is diverted from the malady, by the distraction incident to travel, 
aided by change of scene and climate. 

Prognosis. — Pruritus senilis is usually an intractable disorder, 
and, when dependent upon senile alteration of the cutaneous 
tissues, is incurable. For all other forms of the disease, a prog- 
nosis should be formulated with reserve. Under the influence 
of S3'stematic and appropriate treatment, the happiest results are 
often obtained. Other cases, especially those associated with 
hypochondriasis, may bid defiance to all remedial measures. 
Relapse of the local forms of the malady, especially of .that of 
the ano-genital region, is sufficiently common. In many of 
these patients the treatment serves merely to palliate the disor- 
der which recurs with every renewal of the cause. 

Pruritus Hiemalis. 

Under this title, Duhring 1 was first to describe a harsh and 
pruritic condition of the skin, essentially unattended by struc- 
tural alteration, invading all surfaces of the body, but chiefly the 
inner faces of the thighs, the calves of the legs, and the neigh- 
borhood of the joints of the lower extremities, usually occurring 
in the fall of the year, and continuing until the following spring. 
It possesses many features in common with the forms of pruritus 
already described, including variability in the subjective sensa- 
tions awakened, nocturnal exacerbation, and the absence of a 
primary eruption. The secondary results are also similar, being 

1 Phil. Med. Times, Jan. 10, 1874. 
24 



370 DISEASES OF THE SKIN". 

sequels of self-inflicted injury in the form of roughness, peri- 
follicular redness ami papulation, torn and fractured hairs, ex- 
coriations, blood-crusts, and. in severe eases, an induced derma- 
titis. It. however, abates in Beverity with a rise of atmospheric 
temperature, though the author has occasionally noted persist- 
ence of the distress alter such weather changes. The affection, 
moreover, is one which occurs in persons otherwise enjoying 
perfect health, in those of every social grade, irrespective of the 
character of the clothing worn, and of the habitual use or 
neglect of the hath. It is, without question, a disease of north- 
ern climates, and' more particularly, it seems to me, of climates 
like our own, where the variations of temperature hetween the 
extreme- of the summer and of the winter, range between one 
hundred and one hundred and twenty-five degrees Fahrenheit. 
The careful description of the author presents a picture whose 
accuracy is verified by clinical observation, and which justifies 
the recognition of the disease as a special variety of cutaneous 
pruritus. Its treatment is, in the main, that detailed above, 
the author himself laying- stress upon emollient unguents, glyce- 
rine in the form of lotion or ointment, and alkaline baths. In 
my experience the dusting powders, when employed after the 
tepid bath, have proved more serviceable than any fat-contain- 
ing substances. 

Hyperesthesia. 

This is a condition characterized by exaggerated sensibility 
unattended by structural changes in the skin. It may be idio- 
pathic or symptomatic, general or partial, unilateral or bilateral, 
and may also vary greatly in the degree of abnormal subjective 
sensation by which alone it is declared. In mild eases, there is 
unusual sensitiveness upon contact with foreign bodies, such as 
the clothing; in others, the distress occasioned by even the 
passage of a feather over the surface, is almost intolerable. The 
symptomatic variety of the malady is most common, occurring 
as one of the several manifestations of hysteria, tetanus, and 
other nervous disorders, including certain forms of motor para- 
lysis where sensation has been retained though in a perverted 
condition. The disease is properly classed with the neuroses of 
the skin, with respect to whose etiology and pathology much 
remains to be investigated. 

Anaesthesia. 

In this condition there is total or partial diminution of sensi- 
bility, with and without structural alteration of the skin. As 
in the affection just described, the disorder may be either idio- 
pathic or symptomatic, general or partial, unilateral or bilateral, 
and in varying grades of severity. Illustrations of the disease 



DERMATALGIA. 371 

are furnished in the anaesthetic patches of leprosy which may 
and may not exhibit textural skin changes, the disorder result- 
ing from involvement of the nerves. Other diseases and condi- 
tions may he accompanied by partial or total loss of cutaneous 
sensibility, including centric and excentric paralyses ; syphilitic, 
hysterical, and ataxic disorders; partial or complete anaesthesia 
of artificial production ; the several toxic narcoses, traumatism 
of nerves by pressure, wound, or contusion ; the local anaesthesiae 
induced by cold, frigorific mixtures and substances capable of 
benumbing the sensitiveness of the skin ; coma, of whatever 
origin ; and a number of idiopathic cutaneous disorders, including 
certain of the atrophies, scleroderma, and morphcea. 

A curious divorce occasionally obtains between the elements 
which together constitute the compound sensory impression de- 
rived from the touch. The recognition of pain, of degrees of 
temperature, as also of the form, size, density, distance, weight, 
resistance, and other properties of foreign bodies, is accomplished 
largely by the sensory nerves: and the power to appreciate one 
or several of these objective qualities may be in different degrees 
impaired. In this respect several forms of what, for want of a 
better term, may be named cutaneous anaesthesia, are comparable 
to the conditions recognized in color-blindness. Thus, in some 
cases, there is appreciation of heat, but not of cold ; of form, and 
not of weight; of pain, and not of objective qualities; and the 
reverse. A curious illustration of this occurred in the person of 
a leper under my observation, whose hands were in all parts 
quite sensitive to the prick of a lancet and to contact with heated 
substances; who yet exposed them for hours, without protec- 
tion, to an atmospheric temperature of ten degrees below zero, 
without becoming aware of even slight discomfort. 

Dermatalgia. 

In this morbid state, the integument becomes the seat of pain- 
ful sensations, w T hich may and may not be associated with a 
byperaesthetic condition. The disorder is much more frequently 
sjnnptomatic than idiopathic, and partial rather than general, 
being in the larger number of cases a local expression of some 
disease of the nervous centres or tracts. It is observed usually 
in middle life, and in women more than men. Its symptoms 
vary in severity and in character. The pain is differently de- 
scribed as comparable to that produced by friction, incision, 
penetration, contusion or burning of the integument, as also to 
the passage over the part, of streams of very hot or cold water, 
or the electric current. With this there is commonly associated 
an undue sensitiveness to contact with foreign bodies. The 
skin presents no objective signs of disease. The disordered 
sensations may be limited to the scalp, the region of the spine, 
or the palmar and plantar surfaces. In the latter situation 



372 DISEASES OF THE SKIN. 

it is often significant of some obscurely developed systematic 
disease, such as By philis, rheumatism, or locomotor ataxia. In 
a middle-aged woman, lately under my charge, a persistent 
dermatalgia of the interscapular region was associated with 
coft firmed gastric dyspepsia. In other cases the disorder is de- 
pendent upon disturbance of the uterine function. It is occa- 
sionally observed as one of the rare signals of the occurrence of 
tin- menopause. 

It is to be noted that the severe dermatalgia associated with 
disorders of the uterus in women, is occasionally succeeded by 
a cutaneous lesion. In a middle aged dysmenorrhceic patient 
under my charge, a pea sized hemorrhagic bulla appeared over 
the forehead alter several weeks of frontal suffering. Buck, 1 also, 
reports dermatalgia of the brow and wrists in a young woman 
who had frequently miscarried, followed by recurrent formation 
of a vesicle which accomplished its career of rupture, crusting, 
and erosion, in a stadium of from five to seven days. 

The disease is to be differentiated from pruritus and hyper- 
esthesia of the skin, as also from the affections of deeper parts, 
muscular, nervous, aponeurotic, and visceral. Severe pain, 
limited strictly to the skin of the lumbar region, with hyper- 
esthesia, may precede the occurrence of peri-nephritic abscess. 

The treatment is to be directed to the disorder, of which, in 
tbe great majority of cases, the dermatalgia is merely a local 
symptom. Temporary relief may, however, be afforded by the 
local application of the rubber bag filled with very hot or very 
cold water; sometimes by an alternation of the two, each for a 
few moments at a time. Sponging of the part with very hot 
water is also useful, continued for longer periods, and followed 
by swathing in cotton batting covered with the Lister protective. 
The anodynes may also be used topically with advantage; es- 
pecially the oils, combined with opium, aconite, belladonna, 
and stramonium. I have in some cases procured relief by paint- 
ing the part with Squibb's oleate of mercury and morphia, a 
preparation particularly well adapted to meet the indications 
presented. The skin should generally, in the interval of appli- 
cations, be protected by a dusting-powder; and the clothing 
worn next the skin be of an unirritating character. Care should 
be taken in dermatalgias limited to the trunk of women, lest 
the corsets be responsible for the mischief. The prognosis de- 
pends upon the nature of the cause of the abnormal sensations. 
In general it may be said, that these cases are less persistent 
and annoying than those of confirmed cutaneous pruritus with 
melancholia. 

A series of rare and singular cutaneous phenomena, due with- 
out question to abnormal conditions of the nervous system, are 
recorded by several authors. But little is known regarding 

' Phil. Med. and Surg. Reporter, Jan. 18, 1881, p. G97. 



NEUROMA. 373 

either the possible range of their clinical symptoms or their 
pathology. Of these isolated cases, it may be remarked, that 
they differ greatly among themselves. To this group belong 
the Neurotic Excoriations of Sir Erasmus Wilson, 1 an example 
of which was lately shown at the International Medical Con- 
gress of London. The Bleeding Stigmata which attracted the 
attention of the French and Belgian authorities in the years 
1873-75 belong to the same category. Leloir and Dejerine pre- 
sented another similar case at a recent meeting of the Societe 
de Biologie, in Paris. A young girl of a family, several mem- 
bers of which were affected with nervous diseases, had, without 
any apparent cause, several patches of superficial gangrene 
developed on the cheeks; the small eschars soon separated, leav- 
ing a linear cicatrix, which gradually became transformed into 
cheloid elevations. The first happened three years since, and 
during this period she has suffered from several similar lesions 
on the trunk and arms. The lesion began on the skin, by a 
sensation of pricking, with slight redness and notable diminu- 
tion of sensibility at this point; in nine hours a white patch, 
not preceded by phlyctenula, formed and underwent, after a 
short time, superficial gangrene. Later the spot became brown- 
ish, detached at the edges, and was finally eliminated, leaving 
an ulceration and a cicatrix, the anaesthesia which existed around 
the part finally disappearing. 



2. Neoplastic. 

Neuroma. 

Beriv. Gr. vsSpov, nerve. 

Neuroma is a disease characterized by the occurrence of single or multiple, pin- 
head to nut-sized, usually painful cutaneous papules or tubercles, constituted 
of a new growth of connective tissue and non-medullated nerves. 

Symptomatology. — But few cases of this rare disease are re- 
corded. The description appended is a summary of the symp- 
toms detailed in the reports of Duhring, 2 of Rump, 3 and of 
Kosinski. 4 

The patients were all men of middle life or advanced years, 
who exhibited upon the shoulders, arms, thighs, or buttocks 
numerous disseminated and defined, pin-head to hazel-nut sized, 
roundish or ovalish nodules or tubercles. They were either 
painful, or painless at the onset and painful later. In Rump's 

1 Lectures on Dermatology, London, 1875, p. 192. 

2 Case of Painful Neuroma of the Skin, Amer. Journ. of the Med. Sciences, 
Oct. 1873 ; also Supplement to the same, with cuts, Amer. Journ. of the Medi- 
cal Sciences, Oct. 1881. 

3 Arch, of Path. Anat., bd. Ixxx., hft. 1. 
« Ctblt. f. Chir., No. 16, 1874. 



374 



DISEASES OF THE SKIX. 



case, which was a sample of the false neuromata of Virchow 
(fibroid rumors of the nerve), there was no pain throughout the 
course of the disease. 

The nodules were not arranged along the tracts of nerves; 
were immovable, dense, and elastic; were fixed in the corium 
and extended below it. They were purplish to pinkish in color; 
and the -kin between them was unaltered, or like that envelop- 
ing the lesions, dry. uneven, and desquamative. The tubercles 
were both lender and painful, the pain being excruciating, 
paroxysmal, usually lasting in Duhring's case for an hour, and 
radiating. It was aggravated by temperature changes, mental 
emotion, and movement. 

Sections of the growth in Duhring's case showed anatomically 
a connective tissue stroma, interwoven with fibres for the most. 
part lying parallel with one another, each fibre composed of a 
finely granular central substance surrounded by a sheath con- 
Fig. 37. 




Painful neuroma of the skin ; external appearance. (Dnhring.) 



taining numerous, elongated, oval, somewhat granular nuclei. 
There was also yellow elastic tissue, bloodvessels with thickened 
and nucleated walls, and about the latter lymphoid, cell-like 
bodies. There was entire absence of unstriated muscular and 
fibrillar connective tissue. The specimen was certainly unique, 
representing the true amyelinic neuromata of Virchow. In 
Kosinsk'fs case, non-medullated nerve fibres and connective tissue 



NEUROMA 



375 



were also discovered. In both cases, exsection of a portion of 
nerve (brachial plexus, of the one; and small sciatic, of the other) 
was followed by considerable diminution of the pain, and almost 
entire disappearance of the growths. In Rump's case, which, as 
stated above, represented the fibromata and so-called tibro-nucle- 

Fig. 38. 




pic structure of neuroma, from the same case as Fig-. 37. (Duhring.) 



ated tumors of Virchow, the nodules were strung upon the same 
nerve, " like beads upon a rosary," and were similarly displayed 
upon its branches. Spinal, cerebral, and sympathetic fibres were 
all involved. 

Duhring, in commenting upon these interesting cases, calls 
attention to the distinction between these purely cutaneous 
lesions and the generally solitary, movable, and " painful sub- 
cutaneous tubercle." 



376 DISEASES OF THE SKI. V. 



Class VIII.— OF THE PIGMENT. 

1, Hypertrophic. 

Lentigo. 

Derir. Lat. lens, a freckle. 

Lentigo is tbat condition in which occur pin-head to bean-sized, yellowish to 
brownish, circumscribed, and usually multiple maculations of the cutaneous 
surface, due to an excessive deposit of pigment. 

nptomatology. — This condition, termed also ephelts, is due 
to excessive and irregular deposit of pigment in the skin, pro- 
ducing the pin-head to bean-sized spots of circulate or irregular 

outline, frequently grouped and even confluent, which are com- 
monly designated as ''freckles." They are most frequently seen 
symmetrically distributed on the parts of the body ordinarily 
exposed to the light and heat of the sun and atmospheric influ- 
ences, such as the face, the neck, and the hacks of the hands in 
persons of both sexes. In those whose bodies are to a greater 
extent similarly exposed, they occur upon the chest, the back, 
and over the extremities In other individuals, they may be 
seen upon parts not thus exposed, such as the penis, the scrotum, 
and the inner faces of the thighs', a fact which indicates that 
they are not always the result of the operation of the agencies 
noted above. They vary in color from light yellow, salmon, and 
red to the deepest brown; and are most noticeable in persons 
having red hair and a delicate skin. They occur rarely in in- 
fancy, partly, perhaps, on account of the infrequency of out-door 
exposure in tender years; and are usually seen first about the 
age of six to eight years. They are commonly observed in 
mulattoes, individuals of a race particularly disposed to the 
anomalies of pigment distribution. Once developed, the lesions 
may persist through life without marked alteration; or fade 
with each recurrence of the season of winter; or, in milder cases, 
entirely disappear. They usually share in the atrophic changes 
of old age, and, when persisting to that period, may then spon- 
taneously disappear. They are not the source of subjective sen- 
sation. 

Etiology.— Freckles are, without question, produced and ag- 
gravated at times by the action of the light and heat of the 
sun, as a common experience declares; but it is evident that 
these forces must act upon a susceptible skin. Of a hundred 
sailors exposed in precisely similar situations on a long cruise, 
some of the number will be uniformly "tanned," and others 
deeply "freckled." Attention has been called to the occasional 



CHLOASMA. 377 

occurrence of lentigo in the protected parts of the skin. Dr. 
White, of Boston, in an interesting paper on melanoderma, 1 calls 
attention to the fact that exposure to sea-air and fog, with 
obscuration of the sun, is sufficient to produce the result. 

The pathology and treatment of lentigo are those of the dis- 
order next to be described. 

Chloasma. 

Deriv. Gr. x^H^i to possess a greenish color. 
Chloasma is that condition in which occur yelloAvish to blackish, finger-nail 
to palm-sized, circumscribed, diffuse, and ill-defined maculations of the cu- 
taneous surface, due to an excessive deposit of pigment. 

Symptomatology.— -In this affection the skin is either diffusely 
discolored in various shades, or the maculations occur in patches 
larger than those of lentigo, fairly well-defined, and irregular 
in contour. In color they vary from a scarcely perceptible 
staining of the skin, which requires a strong light for its detec- 
tion, to a deep yellow, a yellowish green, a chocolate-brown, or 
a blackish shade (melanoderma). They may be either, idio- 
pathic or symptomatic in character. 

The idiopathic varieties of chloasma are produced by all ex- 
ternally operating agencies, in consequence of which an undue 
afflux of blood is persistently determined to any portion of the 
skin. It is largely from the blood that the pigment is derived, 
and hence the stains produced by the latter are, to a certain ex- 
tent at least, proportioned to the hypersemia, stasis, or extrava- 
sation of the vascular fluid. Among these externally operating 
agencies may be named, pressure and friction (as over the part 
covered by the pad of a truss); traumatism (as after the severe 
scratching of the skin affected with lice, eczema, or scabies) ; 
heat (as in the diffuse "tanning" of the face, or "sunburn" fol- 
lowing exposure to the solar rays); and the toxic or irritating 
effect of externally applied substances, such as mustard, capsi- 
cum, cantharides, and other articles capable of producing either 
vesication or pustulation of the surface. The physician should 
always remember the possibility of producing long, persistent, 
or even permanent pigmentations of the skin upon the face, 
shoulders, and bosom of young women especially, by the re- 
peated operation of such topical medicaments. 

The symptomatic varieties of chloasma are the results of dis- 
orders either systemic or involving the internal organs. They 
occur as either circumscribed or diffuse, localized or generalized, 
spots, mottlings, stainings, or " masks" of the skin ; and vary in 
color from the lightest shades to the darkest. One of the most 
common, and at the same time the most marked of these, is 
chloasma uterinum, so called because of its frequent association 

1 Boston Med. Journ., May 16, 1878, p. 624. 



378 DISEASES OF THE SKIN. 

with certain physiological or pathological conditions of the ute- 
rus, both union-- married and single women. Thus in pregnancy, 
sterility, hysteria, chlorosis, ovarian disorders, and tumors and 
functional derangements of the uterus, there can be observed at 

times a facial discoloration extending equably over the forehead 
and reaching nearly to the line of the hairs at the Bcalp, in the 
form of a taint or decidedly yellowish, reddish-yellow, or deep 
brownish tinge. At other times, the discoloration is macular 
and asymmetrical, involving the lids, the cheeks, the lips, or the 
chin. When the chloasma assumes the mask-like form, it is 
usually most pronounced over the forehead, hut may involve the 
whole facial region, beiug less distinctly defined below than 
above. Similarly, the well-known changes occur in the areola 
of the nipple, along the linea alba, and about the external geni- 
talia. 

Melanoderma, or Chloasma, Cachecticorum, 

is another of the sj-mptomatic pigment disorders, characterized 
by the changes in the color of the integument of the subjects 
of tuberculosis, syphilis, cancer, chronic alcoholism, malaria (e.g., 
" Chagres fever"), and disorders of the supra-renal capsules (Ad- 
dison's disease). The peculiar tint in each may vary. That of 
the last-named disorder ranges from an olive-green to a dark 
mulatto shade, most pronounced upon the face and hands, the 
regions of pressure and exposure, and those of largest natural 
pigment supply. There is, however, nothing characteristic in 
this, as careful study of Addison's disease discloses the fact that 
its subjects are in many cases affected also with one or another 
of the several diseases exhibiting chloasma cachecticorum. 

Among the cutaneous disorders capable of producing skin 
pigmentation may be named scleroderma, lepra, xeroderma (of 
Hebra), eczema, especially e. venis varicosis; and general exfolia- 
tive dermatitis. 

From all of the discolorations named above, which are due 
solely to deposition in excess of coloring matters normally ex- 
isting in the skin, it is necessary to distinguish the various dys- 
chromia} which are owing to the introduction into the integu- 
ment of coloring substances, either supplied by other portions 
of the body or entirely foreign to it. Thus, in icterus, the bile 
may color the skin from a light yellow to a dark chrome color, 
the duration and severity of the cutaneous symptoms depending 
upon the nature and gravity of the hepatic disease. It is fre- 
quently accompanied by pruritus in various grades of severity, 
the exact causes of which are obscure. 

In arc.yria, the bluish, bluish-gray, slate-colored, or bronzed 
coloration of the skin, results from the introduction from with- 
out, of the nitrate of silver. It is most commonly the result of 
the administration of the drug in the treatment of epilepsy, but 



CHLOASMA. 379 

is said also to have resulted from the topical application of the 
silver crayons to the throat, to the conjunctiva, and even to the 
skin. Under what form the silver produces this effect, whether 
as an albuminate, or other salt, is not known. The deposition, 
however, occurs in the form of minute particles of the metal in 
the connective tissue of the derma. The discolorations are most 
evident upon the parts of the skin exposed to the light, as the 
face and hands; but I have seen the chest and lower extremi- 
ties similarly stained. The connective tissue of the viscera is 
also at times involved, showing thus that the action of light is 
not essential to the production of the dyschromia. 

By the process of tatooing also, several mineral and vegetable 
substances are directly introduced into the corium by means of 
needles, for the production in the skin of various devices in 
colors. Individuals whose entire integument has been thus 
artificially covered with figures of different patterns by tatooing 
with indigo, vermilion, and cinnabar, have been from time to 
time exhibited in this country. The results are indelible. Post- 
mortem, these pigments have been discovered not only in the 
derma, but in the lymphatic ganglia nearest the site of their in- 
troduction. 

Pathology. — The lentigines, ephelides, and chloasmata, are all 
due to excessive deposit of the natural pigment of the body in 
the rete mucosum of the epidermis. Restoration of the normal 
color of the skin is usually proportioned to the extent and depth 
of the deposit, but the process is always very gradual. It can 
be well studied in the slow bleaching of the pigmentation of 
syphilitic cicatrices upon the lower extremities. In the dis- 
chromise due to the introduction of coloring matters foreign to 
the body or foreign to the skin, the corium and subcutaneous 
connective tissue are commonly stained. 

Diagnosis. — The diagnosis of the cutaneous pigment hypertro- 
phies, is readily effected by observing the persistence of the 
discoloration under pressure; the absence of all symptoms of 
hypersemia, inflammation, and secondary changes in the skin ; 
as also by the characteristic shades of color presented to the 
eye. In tinea versicolor, there is usually slight furfuraceous des- 
quamation ; and the existence of a vegetable parasite is readily 
demonstrable by the microscope. The rare pigmentary syphilide 
is usually seen upon the neck and shoulders of infected women 
in the form of yellowish to brownish maculations, often arranged 
in an irregular network. It is, indeed, one of the symptomatic 
chloasmata. 

Treatment. — In all the symptomatic pigment anomalies, the 
indications for treatment are presented by the disease which be- 
gets the cutaneous disorder. 

The local treatment of both the idiopathic and symptomatic 
varieties of the disease, demands the use of external applications 
which will hasten the physiological reproduction of the epi- 



3S0 



DISEASES OF THE SKIN 



dermis, substituting thus new and unpigmented for old and pig- 
mented epithelia. This must also be accomplished without the 
artificial production of such an hypersemia as will tend to add 
to the very coloration which it is attempted to relieve. The 
substances used for the slow accomplishment of this cud, are 
muriatic and acetic acids, borax, sulphur, tincture of iodine, 
potash, and soda (including the soaps of these alkalies), and the 
mercurials. None of these are more generally employed than 
corrosive sublimate, which constitutes the basis of most of the 
cosmetic lotions sold in the shops. 

The following are formulae given by Dr. White, 1 for use in 
the evening. The preparation in each case should he left 
upon the surface during the night, and removed by a soap and 
water washing in the morning. They are to he used for weeks 
in succession, but only after a cautious preliminary testing of 
the sensitiveness of the skin to their action. In order to avoid 
the possibility of error, the practitioner would do well to order 
a poison label upon all vials containing the sublimate: — 



K. 



Hydrarg. am. chlor. ? 
Bismuth, magistr. i 
Amyli, ) 

Glycerin, $ 

Amnion, muriat 
Aq. Colognien. 
Aq. 

Hydrarg. bichlorid. 

Acid. mur. dil. 

Glycerin. 

Alcoholis. ) 

Aq. ros. $ 

Aq. 



aa 3>j 



3ss; 

m-, 

Oss; 

i'3J; 

& m ; 



16 



30 
250| 

4 
30 

60 

130' 



The following are formulae for ointments given by Kaposi: — 



Hydrarg. amnion ) 
Sodse biborat. ) 
01. rosmarin. 
Unguent, simpl. 

Acid, boracis. ) 

Cerae alb. $ 

Paraffin. 

01. amygd. dulc. 



aa 5SS ; 
gtts. x ; 

sj ; 
aa 3j ; 

5u; 

a; 



8 
30 



M. 



The rapid removal of pigmented patches is accomplished, in 
Vienna, by covering the part with strips of linen dipped in an 
aqueous or alcoholic solution of corrosive sublimate of the 
strength of four grains (.26) to the ounce (32.) with which also 
the dressing is occasionally moistened. Vesiculation is usually 
accomplished in about four hours, when the serum is evacuated 
by puncture, and the detached epidermis covered with any inert 
dusting powder. The resulting crust falls in about eight days. 



Loc. cit. 



N^VUS PIGMENTOSUS. 381 

The procedure is attended with the danger of producing, in the 
end, the precise deformity which it seeks to remedy, a danger 
explained above. 

The internal administration of the iodide of potassium recom- 
mended for the removal of argyria, has in my hands failed of any 
good results. YandelPs two patients, one completely and the 
other partially relieved, were both syphilitic. 1 One of my pa- 
tients was a veteran syphilitic, fifty years of age. 

Nsevus Pigment osus. 

Deriv. Lat. ncevus, a mask. 

Nsevus pigmenlosus is a congenital, circumscribed pigmentation of the skin, in 
single or multiple deposits, either without textural cutaneous change, or asso- 
ciated with the development of warts, tubercles, plaques, tumors, or pilary 
hypertrophy. 

Abnormal congenital pigmentations of the skin, vary in color 
from a light yellow or chocolate-brown to a blackish hue, and 
may be single or multiple and very numerous. The}' are com- 
monly termed pigmentary moles. They vary in size from a 
pin-head to tumors of considerable volume; and are either ovoid 
or circular in contour, or so irregularly shaped as to present a 
fanciful resemblance to parts of the figures of the lower animals, 
whence the popular belief as to their origin in maternal impres- 
sions. They occur in both sexes; and upon the face, neck, 
trunk, thighs, buttocks, and external genitals. The term n^vus 
spilus is applied to those which occur in a smooth and other- 
wise unaltered skin; n^ivus verrucosus, to those which are ir- 
regular and wart-like; islevus pilosus, to those surmounted by 
a growth of shorter or longer, stiff or downy, dark-colored hairs; 
and n^ivus mollusciformis, or lipomatodes, to the soft or firm, 
more or less elevated and projecting tumors. 

They may be, when multiple, symmetricall}' or asymmetrically 
developed upon the surface of the body; and in either case may 
confess in their arrangement to a supremacy of the nervous sys- 
tem. In a case reported by myself 2 there were multiple mono- 
lateral pigmentary noevi distributed over the left side of the 
trunk in the course of the intercostal nerves, and in such a 
manner as to strongly suggest to the eye their correspondence 
in site with the lesions of zoster of the same region. De Amicis 3 
had previously reported a somewhat similar case. 

The course of pigmentary nsevi, after obtaining their full evo- 
lution, is to persist unchanged for a lifetime. Their increase in 
tender years is occasionally characterized by a relative rapidity. 

1 American Practitioner, Sept, 1872. 

2 Ch. Med. Journ. and Exam., Oct. 1877. 

3 Lo Sperimentale, March, 1876. 



382 DISEASES OF THE SKIN. 

I have Been a pilary naevus upon the chock of an infant extend 
n\-fv nearly doable its original area in the course of two years. 
They very rarely disappear spontaneously. Their removal 

may be accomplished by excision or destruction with caustics. 

2. Atrophic. 

Albinism. 

Deriv. Dat. albus, white. 

Albinism is a congenital cntaneona achromia, characterized by universal or par- 
tial defect of pigment, unaccompanied by textural changes in the skin. 

Symptomatology. — The term albinism, or leucoderma, is limited 
to the congenital conditions of achromia induced by failure of 
cutaneous pigment. 

Universal congenital leucoderma is peculiar to individuals 
known as Alhinoes, isolated instances of this anomaly occur- 
ring in all races, hut more frequently among those having nor- 
mally a hyperpigmentation of the skin, such as the negroes. In 
the subjects of this deformity, the skin has a milky whitish, 
transparent, or rosy-tinted hue, and is usually of delicate tex- 
ture; the hairs are silky and yellowish, whitish or snowy-white 
in color; the iris, transparent or pinkish ; and the pupil, in con- 
sequence of the defect of pigment in the choroid, is also reddish 
or pinkish. There is, as a result, nyctalopia and heliophobia 
with frequent nictitation, pupillary variations, and the sem- 
blance of myopia. 

Partial congenital leucoderma also is seen in individuals of 
different races, but more commonly in those of African descent. 
When it exists, one or several whitish patches or bands unpro- 
vided with pigment may be seen upon any portion of the sur- 
face; and the hairs found upon such parts are equally destitute 
of normal color. Negroes thus marked are generally termed 
"piebald;" and the integument similarly affected in persons of 
other races has long been recognized as the "pied" or "piebald 
skin." These blemishes are occasionally symmetrical, and, like 
pigmentary naevi, respect in their distribution the areas supplied 
by certain nerves. In this particular, they exhibit a striking 
analogy with the symmetrical arrangement of the spots, bands, 
and stripes to be recognized in the furs of many of the lower 
animals. 

In both universal and partial albinism, the defective condition 
of the pigment is usually unchanged throughout life. Very 
rarely in the latter, there is a tendency to extension in area of 
the uncolored portions of the skin. Still more exceptional is 
the occurrence of pigmentation in previously achromic patches. 
The causes of the deformity are unknown. The few cases of 
inherited albinism on record are not sufficient to establish a law 



VITILIGO. 383 

of inheritance in the face of many instances where such trans- 
missibility has not occurred. The union of a male or female 
albino with an individual of normal color has been repeatedly 
followed by offspring without pigmentary peculiarities. 

The condition is remediless; though it is probable that trans- 
fusion with the blood of a vigorous black-skinned African, would 
largely modify the color characteristics of the pure albino. 

Vitiligo. 

Deriv. Lat. vitium, a blemish. 
Vitiligo is an acquired cutaneous achromia, exhibited in single or multiple, 
variously shaped and sized patches, unaccompanied by textural chauge in 
the skin, and usually bordered by tissues exhibiting pigmentary excess. 

Symptomatology. — The disorder is one observed among the 
several races, often in the negro, and not rarely among those of 
Aryan descent. It commonly occurs without the slightest ap- 
preciable disorder, subjective or objective, save that betrayed to 
the eye in the discoloration of the skin. One or several round- 
ish, or very irregularly shaped, smooth, and well-defined, pale, 
or milky-white disks appear, often bordered at the periphery by 
an integument which assumes a light or dark brown or chocolate 
shade, this hue being by contrast most noticeable immediately 
at the contour of the patch, and imperceptibly fading into the 
normal color of the outlying integument. The hairs or lanugo 
growing from the affected area, may or may not be blanched. 
Most commonly they are ; a condition particularly conspicuous 
when, as is not rarely observed, a vitiliginous disk extends from 
the back or side of the neck, well into the scalp, in which case 
the outline of that portion of the scalp involved is clearly 
defined by the whitened pilary growth. 

The surfaces thus blanched are otherwise unchauged. In 
point of subjective and objective sensation, secretion from the 
follicles, and the condition of both epidermis and corium, aside 
from the dyschromia, there is no departure from a normal 
standard. The disease may progress by the coalescence of rela- 
tively small areas of involvement till a large portion of the 
trunk, thighs, or buttocks is involved. Hall 1 reports the case of 
a dark mulatto who became " perfectly white" with the excep- 
tion of a patch on the chin. It is then, as Kaposi has well 
shown, that the eye of the observer is struck no longer by the 
unusual whiteness of the involved patches ; but this whiteness 
being generalized and apparently that proper to the person, by 
the intermediate peripheral belts of a deeper and unusual color. 
The greater portion of the surface of the body may be finally 
thus involved. The most common seats of the disease are the 
face, the neck, the backs of the hands, and the extremities ; and 

1 Louisville Med. News, 1880, x. p. 148. 



334 DISEASES OF THE SKIN*. 

in these, since the coarse of the disease is exceedingly bIow, there 
may be for years no apparent extension of any involved area. 
Upon the hacks of the hands, the disfigurement is usually more 
conspicuous at Borne seasons of the year than at others, a cir- 
cumstance whi.-h probably explains the reported instances of 
recurrence and total disappearance of the disease in successive 
years. These changes are probably due to the influence of the 
'sweat in washing the pigment to the surface. Such an effect 
would, of course, render the hyper-pigmented peripheral zone 
of a vitiliginous disk much the more conspicuous. 

The health of the subjects of this disorder is usually unim- 
paired. A morbid mental condition is often produced when 
the disfigurement involves the facial region, especially in women 
of middle life. . . 

Etiology.— Vitiligo occurs in both sexes, and in individuals 
of all complexions^ and ages; though it is commonly observed 
in early or middle life, ft is at tunes coincident with sclero- 
derma, morphcea, lepra, variola, and other diseases with similar 
cutaneous symptoms, though it occurs independently of all such. 
Its etiology must be regarded as obscure, unless the strong 
probabilities in favor of its occurrence under the influence of 
perturbed innervation be accepted as conclusive. I am strongly 
inclined to believe that the disorder is of more frequent occur- 
rence than dermatological statistics tend to show. Many per- 
sons who are the subjects of vitiligo of an inconspicuous part of 
the body, do not consult a physician with regard to the nature 
of the disease, as it occasions no physical distress. Close ob- 
servation of the people with whom one comes in contact in 
public will often verify this fact. 

Pathology.— The pathological anatomy of vitiligo may one day 
he described in the changes which occur in the trophic nerves 
supplying the skin. At present, the cutaneous changes alone 
are recognized ; and these are, probably, as regards the pigment, 
neither strictly atrophic or hypertrophic. It is true that there 
is an apparent atrophy in one portion of the skin, and an ap- 
parent hypertrophy in" another; but is not this merely a dys- 
trophia or ataxia of the epidermis, a disturbance ot arrange- 
ment and distribution, as of the blood in the face, m certain 
cardiac diseases, when the skin is temporarily streaked or mot- 
tled by the irregularity in the distribution of the circulating 
fluid? These are undetermined points. 

Diagnosis.— Mr. Hutchinson, of London, has devoted an en- 
tire chapter in his valuable Lectures on Clinical Surgery 1 to the 
importance of the diagnosis between leucoderma and white 
leprosy; yet it seems incredible that the symptoms character- 
istic of a systemic disease could be confounded with those de- 
scribed above, where there is no cutaneous anaesthesia or struc- 

1 Churchill, London, 1878. 



THE EXANTHEMATA. 385 

tural change in the integument. This latter is, in fact, the basis 
of discrimination between all purely pigmentary and all non- 
pigmentary changes in the skin color, separating them widely 
from parasitic diseases (tinea versicolor), morphoea, lepra, and 
syphilis. From the chloasmata, which are always accompanied 
by hyper-pigmentation, vitiligo is readily differentiated. 

Treatment. — lam strongly of the opinion that much chagrin 
will be saved both physician and patient, by practically regard- 
ing vitiligo as not amenable to treatment. Patients occasionally 
recover while under treatment; the latter has, however, gen- 
erally contributed but very little to the result. Arsenic and 
iron internally, recommended highly by some authors, have re- 
peatedly failed to accomplish any appreciable results as regards 
the dyschromia. By efforts directed to the removal of the 
hyper-pigmentation in the border of the achromic patches, the 
disfigurement may be somewhat lessened. The method of arriv- 
ing at this end has been described in connection with the treat- 
ment of chloasma. It is possible that further experimentation 
with hypodermic injections of pilocarpine, which have in a lim- 
ited number of cases been followed by disappearance of the dis- 
ease, may warrant a less unfavorable view of the results of 
treatment. 

Prognosis. — The health of the subject of the malady is not 
impaired. The disease is practically incurable, progressing usu- 
ally till it has obtained a maximum of development; and then, 
as a rule, remaining unchanged throughout life. 



Class IX.— OF THE SKIN" WITH INVOLVEMENT OF OTHER 
ORGANS. 

1. Exudative. 

The Exanthemata. 

Deriv. Gr. I^ovflu^a, blossoming, flowering. 

The exanthemata are specific fevers, frequently occurring in epidemic form, com- 
municable by contagion, preceded by a period of incubation, and character- 
ized by systemic disturbance, with an efflorescence upon the skin of different 
type in each, as also by involvement of other organs of the body, a single 
attack usually conferring immunity, upon an affected individual during his oi- 
lier lifetime, against subsequent attacks of the same disease. 

For a detailed consideration of the phenomena of the exanthe- 
matous fevers, the reader is referred to the standard treatises on 
the subject, in the field of general medicine. Brief space is al- 
lotted here, merely to a description of the cutaneous lesions by 
which they are all characterized. These are unlike in each dis- 
25 



386 DISEASES OF THE SKIX. 

ease; and yet all exhibit certain common characteristics. In 
all, the eruptions arc symmetrical ; and in typical rases, general. 
hi each, the efflorescence i< succeeded by a desquamative or ex- 
foliating condition of the skin. In each there is. within rela- 
tively fixed limits, a distinct stadium of the pathological pro- 
cess, within which it is completed, and beyond which, however 
persistent may he its remote Bequelse, there is no chronic mani- 
festation of the disorder. Each also is produced solely by its 
own specific contagium, derived exclusively from an animal 
body affected with the same disease, being never, so far as 
known, generated from any other source, nor merging by imper- 
ceptible degrees, the one into another. Two of these may rarely 
concur, but under such circumstances the one is always pro- 
nounced in its features, which either closely precede or follow 
those of another. Finally, no specific medication is known to 
be capable of arresting any one of them, each pursuing its course 
uninterruptedly to a favorable or fatal termination, according 
to the intensity of the poison present in each case, and the more 
or less favorable or unfavorable conditions of the sufferer. 

Rubeola (Measles, Morbilli). 

This disease is preceded by a period of incubation, lasting 
from eight to twenty-one days, a period in which there may he 
no evidence of ill health, or merely a moderate degree of lassi- 
tude and inappetence. To this succeeds a prodromic fever, the 
temperature rising to 103°-l(H o F., occasionally alternating 
with chills or a sensation of chilliness, dryness of the skin, pains 
in the head, thirst, occasionally sweating, very rarely convul- 
sions in infancy; and, almost invariably, a serous catarrh of 
the mucous surfaces. By the second or third day, the tempera- 
ture begins to decline, while the catarrhal symptoms increase. 
These are manifested by sneezing, a secretion from the eyes and 
nose, and engorgement of the exposed mucous surfaces, espe- 
cially those of the conjunctiva, mires, and throat. Occasionally, 
the tongue and fauces exhibit a few isolated, minute, reddish 
puncta. In consequence of the implication of the larynx, 
trachea, and ultimately the larger bronchi, there is a hoarse, 
frequently an incessant and teasing, cough of a convulsive char- 
acter, accompanied by expectoration of a moderate quantity of 
mucus. This prodromic period lasts for from three to live days, 
but is, in exceptional cases, prolonged to twice that length of 
time. Upon its conclusion the exanthem appears, usually with 
exaggeration of the fever, the temperature rising to 104r°-106° 
F., and remaining at that point till the eruption has reached its 
apogee, wheu it commonly declines -pari passu with the severity 
of the skin symptoms. 

The eruption of measles appears usually first upon the face 
(the forehead and temples), and thence extends in about thirty 



THE EXANTHEMATA. 387 

hours over the neck, upper portion of the trunk and superior 
extremities. Between the fourth and sixth days of the disease, 
it has usually attained its maximum of development over the 
entire surface of the body, including the palms and soles, and 
its deepest shade of color. This maximum attained, the erup- 
tion gradually fades; the tumid condition of the skin, most 
noticeable upon the face, also subsides; the catarrhal symptoms 
and cougb become less annoying; and the patient enters upon 
the period of desquamation. 

The eruption is characterized by the occurrence of reddish, 
yellowish-red, mulberry-red, deep raspberry-red, or, in extreme 
cases, violaceous-tinted, small finger-nail sized macula?, either 
not elevated or very slightly elevated above the general level 
of the integument; or by the occurrence of large-pin-head sized, 
discrete papules, much more rarely pin-point sized vesicles, cor- 
responding in color to the shades described above, and highly 
suggestive of the first efflorescence in variola. These lesions 
pale under pressure, exhibiting then a yellowish tint, and are 
often set together very closely in patches suggesting a crescentic 
outline. The term "suggesting" is here used purposely; as it is 
difficult by selecting a single patch to determine by the eye alone 
the existence of such a configuration ; while yet an examination 
of the eruption as a whole, may often very clearly convey this 
impression to the sight. In other words, the crescentic outline 
is far less distinct than, for example, in certain of the papulo- 
crustaceous syphilodermata, Usually patches of sound skin can 
be recognized, even when the eruption appears to be confluent, 
complete confluence never occurring so as to form a sheet or mask 
over an entire area of the skin. Individual lesions may so merge 
as to be well-nigh indistinguishable separately; yet, on the 
whole, the eruption deserves fully the plural character of its 
English name. It is made up in all cases of innumerable ele- 
ments, whose identity is never wholly lost. The subjective sen- 
sation awakened is occasionally a severe itching or burning; 
frequently this is a matter of insignificance in comparison with 
other disagreeable symptoms, e.g., the cough, coryza, and fever. 

Desquamation is accomplished usually with cessation of fever 
and the production of yellowish-brown pigmentations of the 
surface where the elements of the eruption have existed, invo- 
lution being first manifested in the site of the lesions which 
were earliest to develop. Gradually and simultaneously, the 
catarrhal symptoms of the respiratory passages diminish in 
severity. This final stage of the disease is usually terminated 
in- a fortnight from the date of invasion. 

The complications and anomalies of measles depend : upon the 
intensity of the poison, displayed in the most formidable symp- 
toms where human beings are crowded together, as in camps 
and prisons; upon the degree of physical vigor; and also upon 
the various hygienic surroundings of the victims of the disease. 



388 DISEASES OF THE SKIN. 

Thug the period of efflorescence may be unusually prolonged : 
the eruption may disappear bu Idenly, and as rapidly reappear; 
the cutaneous symptoms may alone he wanting; the latter may 
be commingled with petechias due to cutaneous extravasation of 
blood, which may be also accompanied by severe epistaxis; and 
the catarrhal condition of the mucous surfaces affected may ter- 
minate in croupal or diphtheritic disease, may be followed by 
capillary bronchitis, catarrhal pneumonia, and even by pulmo- 
nary tuberculosis. Typhoid conditions may also supervene,and 
chronic inflammatory affections of the eyes and of the Schnei- 
derian membrane result. 

The pathology of the cutaneous lesions in measles, is that 
merely of acute hypersemia occasionally passing into exudation, 
limited for the most part to the vascular papillae of the corium 
and the perifollicular plexuses of blood vessels. Post-mortem, the 
eruption fades, as the result of the gravity of the blood, from the 
anterior aspect of the body as it reclines upon the dorsum. 

The disease is one of infancy chiefly, probably because at that 
aire there is always the largest number of individuals unpro- 
tected by -previous attacks. In every ease, the malady results 
from contagion, mediate or immediate, from an infected human 
subject. It spares no age nor sex, though much rarer in ad- 
vanced years than at other periods of life, probably because of 
the large number who, at such periods, enjoy immunity. 

The diagnosis of importance, is between scarlatina and variola. 
Typical cases with a well-developed eruption can be scarcely 
mistaken for either, if the symptoms displayed are assigned their 
full weight. It would be useless, however, to deny the fact that 
atypical forms occur, which have again and again confused the 
most expert diagnosticians; and in all cases of doubt, the prudent 
practitioner will refuse to decide as to the nature of the disease, 
till the symptoms have, in the lapse of time, bet n fully declared. The 
resemblance between illy developed measles and certain of the 
eruptions seen in varioloid, is in the highest degree striking; 
and it seems to be quite needful to remind the professional world 
that the greatest skill, at a given moment of time, will in cases 
utterly fail to make a decision between the two. A distinctly 
crescentic character of the eruption, the presence of catarrhal 
symptoms, the continuance of the fever after the efflorescence is 
completed, the color of the eruption, and the discovery of the 
nature of the disease from which the contagion was derived, 
will all point in the direction of the truth. From scarlatina, 
measles is much more readily differentiated by the macular or 
papular elements of its eruption ; by their color; by their appear- 
ance to a marked degree upon the face; and by the absence of 
the characteristic sore throat and usually intense febrile access 
of the first named disease. From the various forms of erythema 
accompanied by fever, measles can always be recognized by the 
irregularity of the temperature record, as well as by the charac- 



THE EXANTHEMATA. 889 

ter of the eruption. The distinction between rubeola and ro- 
theln will be given later. 

The treatment of rubeola should be strictly limited to a careful 
hygienic attention to the invalid, including a restricted "fever 
diet," and the use of such medicaments only as are specially in- 
dicated by the complications or accidents of the disease. The 
skin should be anointed with a bland, oily or fatty substance, 
to relieve the pruritic sensations, especially after the sponging 
of the surface once daily with a weak alkaline solution, which 
may be used cool without fear of producing " repercussion" of 
the exanthem. The chamber of the invalid should be some- 
what darkened, for the sake of the eyes, but pure air should 
be constantly admitted. 

The prognosis is in general favorable All the complications 
named above increase, however, the gravity of the disease, which 
is also enhanced among men crowded together in camps, infant's 
in public charities, pregnant women, the cachectic and greatly 
enfeebled from other diseases, vevy young infants, old men and 
women, and islanders long unvisited by epidemics of the malady. 

Rotheln (Rubella, German Measles, Hybrid Measles, French Measles). 

Under these several titles has been described a disorder lately 
very prevalent in this country in epidemic form, accompanied 
by a cutaneous exanthem somewhat resembling that of rubeola, 
and manifestly contagious. 

Kaposi regards this disorder as a mild form of rubeola, since 
the latter, as is well known, may occur several times in the 
same person, and rotheln thus attacks those who have suffered 
from measles. Pie also lays stress upon the identity of the 
symptoms in the two disorders, and the occurrence of transitional 
forms between typical examples of the two, as admitted by G-er- 
hardt and other partisans of the specificity of rotheln. 

In dissenting from so high an authority, I believe that I am 
in accord with the larger number of those who have had the 
opportunity of studying the disease as it prevailed during the 
late epidemic so general in this country. My belief in the indi- 
viduality of rotheln, is based upon a somewhat careful observa- 
tion of more than one hundred typical cases. In the Chicago 
Home for the Friendless, more than sixty per cent, of those who 
suffered from the disease in 1880-1881, had also endured measles 
in 1879-1880. Both epidemics were severe in point of general 
prevalence, and furnished a large number of typical cases of the 
two disorders. The recurrence of measles in so great a propor- 
tion of children in two successive years, would furnish a very 
wide variation from the statistical facts of that malady. In the 
two epidemics, moreover, the symptoms were markedly different, 
and transitional forms did not occur. 

.Rotheln, then, occurs in those who have previously, and even 



390 DISEASES OF THE SKIN. 

within relatively brief periodH of t i me. suffered from measles, 
without a prodroraic catarrh, this symptom when present, being 
coincident with the appearance of the exanthem. It is rarely a 
marked characteristic of the disease, and the affection of the 
eyes is. us ;i rule, much less pronounced than in measles. After 
a pyrexic period, rarely lasting longer than a few hours, and in 
many cases entirely absent, the eruption appears in the form of 
multiple, pin-point to small pin-head sized papules, occurring for 
the most part in the regions affected by measles, but smaller 
than the lesions displayed in that disease, and decidedly lighter 
in color. The shade is a rosy- to a crimson-red, rarely lurid, 
never of dark mulberry or violaceous hue. This color will, at 
times, lie perceptible beyond the line of the lesions, in a delicate 
halo, a circumstance which strongly distinguishes the exanthem 
from morbilli. The lesions, moreover, are seldom arranged in 
crescentic outline, being more often grouped in roundish or oval- 
ish patches. Often indeed the elements of the eruption are dis- 
crete and disseminated. The fauces are occasionally reddened 
in puncta. The eruption commonly hides in from one to two 
days, and there may or ma)' not be slight resulting cutaneous 
desquamation. 

The rash is to he distinguished from that of measles by the 
existence of the features described above, particularly by the 
color, contour, and date of occurrence of the exanthem, the 
transitory character of the fever when the latter is present, and 
the rapidity with which involution of the disease progresses. 
By the temperature record alone of the patient, it may he differ- 
entiated from scarlatina, though the rash is dissimilar in the 
two diseases. It is also not to be confounded with the erythe- 
matous affections of the skin. One of the most striking charac- 
teristics of the disease can be best recognized in a ward tilled 
with children, all of whom are simultaneously affected with the 
disorder. That characteristic is the remarkable mildness of the 
phenomena displayed in every case. I have thus bad under ob- 
servation at one time twenty little patients all exhibiting the 
exanthem, not one of whom presented the peculiar facies of the 
sufferer from measles. 

The disorder, consequently, should he treated by rest in bed, 
a supply of fresh air, and the usual diet of fever patients. I 
have never seen a case calling for medication by drugs. 

Scarlatina (Scarlet Fever). 

This is also a S} r stemic contagious disease, produced b} T poison- 
ous emanations from an infected human being, characterized by 
fever, a cutaneous exanthem, and involvement of other organs 
of the body. 

The period of incubation of scarlet fever varies between 
twenty-four hours and a month or more, the average duration 



THE EXANTHEMATA. 391 

being about eight days. The reason of this wide variation is 
to be sought, not in any changeability in the mode of evolution 
of the disease, but in the fact that its poison is less volatile and 
less rapidly dissipated than is that of measles, the result being 
that it may remain potential for longer periods in connection 
with articles through the medium of which it is transferred 
from one individual to another. This incubative period, like 
that described in connection with measles, may he quite unpro- 
ductive of physical symptoms, or be associated with an ill- 
defined malaise. 

The prodrome of the disease in typical cases, is marked by the 
occurrence of a rapid and bounding pulse, an exceedingly dry 
skin, and a characteristic sore throat. When examination of 
the mouth is made, the tongue is seen to be thickly coated, and 
its filiform papillae reddened and prominent, producing the so- 
called " strawberry appearance." The velum, pillars of the 
fauces, tonsils, and all exposed mucous surfaces are engorged, 
tumid, reddened, and often covered with deep reddish puncta, 
which unquestionably represent hyperasmia of the perifollicular 
tissues. Thirst is great, and deglutition often in the highest 
degree painful. In severe cases, the mucous surfaces named may 
speedily exhibit finger-nail to pigeon's egg sized, ashy ulcera- 
tions with a lurid halo at the periphery. In children, there may 
be syncope, delirium, convulsions, vomiting, or, when the poison 
has been intense, fatal results from shock of the nervous cen- 
tres. This prodromal period usually lasts from twelve to 
twenty-four hours, though it may be prolonged for two days 
more. In this respect scarlatina is markedly distinguished from 
rubeola. It is terminated by the appearance of the exanthem, 
but the fever persists without abatement after the explosion : 
and the other symptoms of the disease are in no wise then ame- 
liorated. 

The eruption in scarlatina usually spares the face, however 
much the latter may display two damask-colored cheeks under 
the febrile flush, become tumid with the acceleration to it of 
the blood pumped through the throbbing carotids, or even ex- 
hibit a few scanty lesions upon the forehead and temples. 
About the mouth, the integument is always pallid. This is far 
different from the picture presented in measles. The eruption 
is first seen in the form of light or deep-red, pin-head sized 
puncta, so closely agglomerated as to produce upon the eye the 
impression of a diffuse reddish blush. It is first seen about the 
neck and clavicular regions, but rapidly spreads to the trunk 
and extremities, including the dorsal surfaces of the hands and 
feet, attaining complete development in the course of the second 
day of the eruption. It is then of a distinctly scarlet color, 
whence the disease has its name in the Latin, English, and Ger- 
man tongues, a coloration frequently compared to the appear- 
ance of a boiled lobster. Upon the limbs it is often developed 



302 DISEASES OF THE SKIN. 

ill punctate form, while the occurrence of a diffuse scarlet blush 
is most distinctly perceived by the eve in the examination of the 

trunk. Here it is seen to fade under pressure; and the finger- 
nail drawn rapidly ever the surface of the skin is followed by 
the formation of a whitish line, which persists for an instant, a 
rime sufficient to enable one to describe a letter upon the skin. 
This period of efflorescence lasts for from one to two days to an 
entire week, during which, as stated above, the febrile and other 
symptoms persist unabated. 

The rash usually persists at its maxim of development for 
from one to three days, the concomitant symptoms continuing 
without noticeable abatement. Among the latter may be named 
the occurrence of albumen in a urinary Becretion of diminished 
gravity, with occasionally the presence of epithelium recogniza- 
ble under the microscope as derived from the lining membrane 
of the uriniferous tubules of the kidney. 

Having attained its apogee, the eruption in favorable cases 
begins to fade, the part first affected exhibiting earliest a lighter 
shade, while the other pathological phenomena diminish in sever- 
ity, the sore throat, especially in ulcerated conditions, alone per- 
sisting. In from four to ten days longer the eruption disappears, 
leaving a brownish-yellow pigmentation of the surface; and 
simultaneously the other symptoms of disease vanish. 

The desquamation which then ensues, as convalescence pro- 
gresses, is general and often proportioned in extent to the sever- 
ity of the preceding eruption, though it may be generalized after 
a well nigh i in perceptible exantheni. It is more pronounced 
and characteristic in scarlatina than in any of the other eruptive 
fevers. It may be superficial and furfuraceous in character; or 
the epidermis may fall in lamellated plates, the sheath of an 
entire finger, for example, with the nail; or that of the entire 
palm. In this way sheets, ribbons, and shreds of the horny 
layer of the skin may fall from its surface, and expose beneath 
a new and often tender epidermis. The hairs may be simulta- 
neously shed. When this desquamation is finished, the stadium 
of the disease may be regarded as concluded, the entire period 
lasting in uncomplicated cases from a fortnight to a month or 
six weeks. 

The complications, anomalies, and remote sequelae of scarla- 
tina are so numerous as to furnish a vast array of facts for the 
study of the pathologist. The reader need be merely reminded 
in these pages, that the usual incubative and prodromic Stages of 
the disease may be brief as to time, or so brusquely followed 
by eruptive phenomena as to be indistinguishable. The latter 
may also first occur upon the extremities or trunk, and later on 
the neck and over the clavicles; or at once cover the totality of 
the surface by a rapid explosion ; or be extremely short-lived ; 
or be altogether absent; or be unusually prolonged and visible 
for even a fortnight upon the surface of the body, appearing 



THE EXANTHEMATA. 393 

and well-nigh disappearing: without appreciable causes. To a 
proportionate extent the stage of desquamation may be preco- 
ciously or tardily reached, and the exfoliating process be tediously 
prolonged and of intense type, jeopardizing in this manner the 
future of the convalescent prostrated by the fever which has 
passed, or the sympathetic fever which may thus be awakened. 

The anomalies of the scarlatinal rash are numerous, but de- 
pend, in general, less upon a variation in the intensity of the 
poison than upon the physical condition of the patient. Thus 
the affected surface may be slightly elevated above the general 
level; may exhibit irregularly disposed mottlings and macula- 
tions ; may be characterized by the occurrence of miliary 
papules, minute vesicles, or purpuric lesions well defined against 
the general scarlet color of the skin by their violaceous shade, 
and due to cutaneous extravasation of blood. The rare bullous, 
pustular, and urticarial lesions which may appear upon the skin, 
are accidental, and boar no relation to the specific history of the 
disease. 

Malignant anginose scarlatina is characterized by the gravity 
of the throat symptoms. In such cases, a parenchymatous in- 
flammation of the tonsils, velum, and fauces supervenes at an 
earl}- period, with enormous tumefaction, involvement of the 
submucous tissue and neighboring glands, and ulcerative, sup- 
purative and even gangrenous results, which may prove speedily 
fatal. Gastro-intestinal disorders may also prove dangerous. 
An otitis externa, media, or interna, may perforate the tym- 
panum, destroy the ossicles, induce caries of the mastoid process 
of the temporal bone, and prove fatal by the eventual produc- 
tion of meningitis or phlebitis. 

Another severe type of the disease is that in which symptoms 
of typhus are pronounced (scarlatiniform typhus). Here the 
patient may perish within a few hours after being attacked and 
before the eruption appears, exhibiting comatose or convulsive 
symptoms indicating the profound influence upon the nervous 
centres of the intensely intoxicated blood ; or the eruption may 
have time to appear, often livid, hemorrhagic, or petechial in 
type, and be followed by albuminuria, meningitis, diarrhoea, 
coma, and death Catarrhal and parenchymatous nephritis are 
justly dreaded during the desquamative period of the malady, 
when they may prove fatal after a relatively benignant mani- 
festation of the disease in its prodromal and eruptive stages. 
To this sufficiently grave list of disorders which may complicate 
scarlet fever, must be added pneumonia, pericarditis, pleuritis, 
peritonitis, chronic purulent nasal catarrh, which may result in 
caries of the nasal bones, destruction of the cornea as a result 
of severe keratitis, persistent adenopathy of the subcutaneous 
glands, and malnutrition in many forms, which may so impair 
the vigor of the constitution as to leave the sufferer a physical 
wreck for the remainder of life. 



304 DISEASES OF THE SKIN. 

The cutaneous lesions of scarlatina, like those of rubeola, 
depend Upon byperaemia and a moderate decree of exudation. 

The latter, when it occurs, is limited for the most part to the rete 
and papillary layer of the coriura. The signs of the disorder 

are not apparent in the dead body, unless there has been exuda- 
tion <>f blood and the consequent formation of petechias. 

The disease is produced exclusively by contagion derived from 
the animal body affected with scarlatina, either mediately or 
immediately. It attacks individuals of both sexes and all ages, 
children and infants more frequently, the aged more rarely, 
probably in consequence of their respective conditions as re- 
gards immunity conferred by a previous attack, since in general 
the disease occurs but once in a lifetime. Individual idiosyn- 
crasy must account for the cases in which unprotected infants 
exposed to the disease fail to receive it, a fact noted occasionally 
in all the exanthemata. The contagious element is volatile in 
its nature, and seems to be most active during the eruptive stage 
of the disease. 

The diagnosis is between rubeola, rbtheln, erysipelas, and the 
erythemata ; and is, in general, readily established. The sore- 
throat, intense fever, the punetiform scarlet rash reaching to the 
border of the inferior maxilla, and the distinct, whitish-yellow 
line traceable by the finger-nail passed rapidly over the surface, 
are all characteristic. In rubeola, the macular character of the 
rash, and its crescentic arrangement, in connection with the 
catarrhal symptoms will usually be recognized. From ery- 
sipelas, scarlatina can always be distinguished by the absence of 
the peculiar, shining, smooth, or glazed and tumid condition of 
the affected area. From all other rashes, scarlet fever can be 
distinguished by the pyrexic symptoms and resulting desqua- 
mation. 

The modern treatment of uncomplicated scarlatina is purely 
expectant, after provision is made for an abundant supply of 
fresh air, disinfection, a proper regulation of food and drink, 
and the local use of baths, tepid or cool, for the purpose of re- 
ducing the bodily temperature. After each of these, the skin 
should be completely anointed with a fatty substance, such as 
cold cream, scented almond or olive oil ; or, what is most com- 
monly used in this country, vaseline. These inunctions are not 
only grateful to the patient, but, as I have again and again de- 
monstrated i.y the thermometer, reduce the temperature to a 
slight degree. All other treatment than that suggested above, 
should be limited to the special conditions presented in each 
case, and pertains to the field of general medicine. It includes 
the management of the disorders of the eye, ear, throat, kid- 
neys, and other viscera, whose involvement constitutes a compli- 
cation of the disease. 

The prognosis of the malady should always be established with 
reserve. It is largely based upon the relative intensity of the 



THE EXANTHEMATA. 395 

symptoms, the vigor and age of the subject, and the presence or 
absence of serious complications. Albuminuria is rarely absent, 
and not per se alarming; but anasarca and other evidences of 
profound interference with the renal function, are to be assigned 
due weight. In general it may be said, that a high range of 
temperature ; early and ulcerative throat lesions ; tardy develop- 
ment, rapid and untimely disappearance or undue prolongation 
of the exanthem ; and its admixture with petechia to such an 
extent as to indicate extensive hemorrhagic extravasation, are 
all formidable symptoms. Finally, it must not be forgotten 
that the mildest and simplest forms of the disease, after the 
fastigium is passed and convalescence actually established, may 
terminate fatally by the supervention of urasmia, cerebral paraly- 
sis, or even meningitis, consequent upon secondary changes in 
the middle or internal ear. 

Variola (Smallpox). 

The variations of this malady as to the severity, character, and 
duration of its symptoms, are so great as to preclude its complete 
description within the limits here assigned to the subject. The 
following paragraphs are devoted to a brief sketch merely of its 
more commonly recognized characters. 

The period of incubation of the unmitigated disease varies 
between ten and twenty days, occupying usually a fortnight. 
It is characterized by the peculiarities of that period recognized 
in all the exanthemata, few and insignificant or no evidences of 
physical discomfort. The prodrotnic stage is ushered in gene- 
rally by a vespertine chill, succeeded by lever, with a tempera- 
ture rising to 104°-106° F., which is commonly associated 
with severe and characteristic pain in the loins, headache, 
nausea or vomiting, and occasionally, in young subjects, delirium 
and convulsions. The fever continues, with alternations of ex- 
acerbation and partial relief, or sensations of chilliness, on the 
second and third days. At the same time there may be faucial 
hypersemia and moderate dysphagia. Occasionally, before the 
cutaneous exanthem appears, minute reddish papules may be 
recognized upon the buccal membrane. 

On the second and third days there appears, in some cases, 
especially in menstruating women and in young subjects, a cu- 
taneous efflorescence, whose significance has been often misin- 
terpreted, and which has led to many errors in diagnosis. It is 
to Hebra that we are indebted for its distinct recognition as a 
cutaneous prodrome in variola. It has been termed variolous 
erythema, and variolous roseola. I regard its recognition as 
a matter of special importance to the diagnostician, having been 
myself, on the first occasion when it came under my observation, 
completely deceived as to its nature and significance. It is 
characterized by the occurrence of irregularly disposed, and dis- 



396 DISEASES OF THE SKIN*. 

tinctly outlined, maculations, puncta, stria?, streaks, or a diffuse 
blush of bright or larid reddish hue; the invaded integument 
being at times Blightly tumid, and thus elevated above the general 
level. It may be also the seat of moderate pruritus. The blush 
may fade under pressure, but rarely does so perfectly. One cannot 
by the finger produce upon it a visible whitish spot. It. occurs 
most often about the groins, hypogastric region, pubes and inner 
faces of the thighs; and, examining these parts, the physician 
will usually discover the evidence, in adult women, of recent 
or present menstruation, or of the puerperal state. It occurs 
also about the axillae, the extensor faces of the larger and smaller 
joints, and the lumbar and clavicular regions. Often a broad 
area of the integument in these parts may exhibit a sheet or 
mask of dull crimson erythema, upon which pin-head to bean- 
sized dull-reddish papules may form, not losing their color under 
pressure, more rarely petechias, vesicles, and wheals. All these 
are precursory phenomena, and are not transformed into charac- 
teristic variolous lesions. They fade almost completely before 
the latter appear. Rarely, a few scattered papules may be dis- 
tinguished upon the face and arms before the variolous erythema 
fades. Often the former in full development are even less pro- 
fusely displayed in the site of the precedent efflorescence. The 
latter need not be necessarily regarded as a symptom of por- 
tentous gravity. I have seen the entire surface of the bell}* 
covered with a uniform erythematous blush of dull crimson hue, 
confluent variola follow, and the patient ultimately recover. 
The physician, then, in face of a deep-red erythema of the re- 
gions named, especially of the groins, lower part of the belly 
and thighs of a menstruating woman, affected with high fever, 
nausea, vomiting, and lumbar pain, should invariably suspect 
the presence of variola. 

The period of eruption is characterized, at its earliest, by 
punctiform, subcutaneous discolorations which photography 
alone can reveal. Commonly, after three days of prodromic symp- 
toms, the patient will be seen on the morning of the fourth with 
the face and scalp covered by pin-head sized and larger, firm 
conical papules, whose impression to the finger is compared by 
most English writers to the feeling of shot. Later, these de- 
velop upon the trunk and limbs; and in well-marked cases 
every portion of the surface of the body is invaded, including the 
palms and soles. The lesions may be surrounded by a narrow 
rosy areola upon the trunk. They may be unproductive of sub- 
jective sensations, or be slightly tender. 

As a rule, there is complete defervescence when the exanthera 
appears, the patient experiencing such relief that if an adult has 
chanced not to view the face in a mirror nor to be informed of 
his appearance by those in attendance upon him, he will often 
regard himself as completely relieved of his three days' illness. 



THE EXANTHEMATA. 397 

In other cases, the febrile symptoms persist, with a lowered 
temperature. 

During the first two days of the eruptive period, the papules 
increase in number, and become correspondingly agglomerated; 
while those of earliest appearance become transformed into vesi 
cles containing a translucent serum, the roof- wall of many of 
them exhibiting an umbilication. This umbilication of the 
vesicle is characteristic, and slightly different from that observed 
in bullous and pustular lesions. The central depression is dispro- 
portionately large, and about it the yet undistended epidermis 
is often irregularly puckered or fluted. Even in this period, the 
lapse of a few hours will produce a lactescent appearance in 
their formerly translucent contents. 

From the eighth to the twelfth day, the transformation of 
these lesions into pustules is effected, the process beginning, as 
in all the metamorphoses, of the disease, in the vesicles of greatest 
ao'C ; those, namely, on the face and upper portions of the body. 
The lesions simultaneously enlarge till they are of the average 
size of a pea, and, being fully distended, rupture the centrally 
placed filament which held down the roof wall, in consequence 
of which the umbilication of the pustules is lost. With this 
process of suppuration, is awakened the so-called secondary fever, 
a pathological process evidently not essential to the disease, as 
it does not occur in mitigated cases. It is born of the extensive 
process of suppuration, occurring in the skin and other organs, 
and may be symptomatic, sympathetic, or septicemic in charac- 
ter. It thus varies in different cases with the character and 
severity of the processes by which it is excited, being transitory 
in mild cases, and in others terminating only with death. At 
this time the patient is usually in a most distressing condition. 
The skin of the face and other attacked regions is swollen, 
thickly covered with pustules, and the features indistinguish- 
able in the tumid and closed lids, the cedematous lips, disfigured 
nostrils, and pus obstructed mucous outlets. Deglutition be- 
comes painful and often impossible ; the saliva flows from the 
lips; and the mucus of the nares dries with the pus upon the 
exterior of the visage. The pustules recognized upon the in- 
tegument are represented also in the gastro-intestinal tract. In 
an autopsy of a patient dead at this stage of the disease, made 
by myself in company with Dr. McGill, of the United States 
Army, during the late civil war in this country, we discovered 
the entire canal from the mouth to the anus, as also the genito- 
urinary and respiratory passages, completely covered with closely 
agglomerated and well-distended pustules. The career of those 
within the mouth can be usually studied by observation with 
the eye. In this situation they rapidly lose their epithelial roof- 
wall by reason of the heat, moisture, and friction, to which the^v 
are subjected, and then exhibit a reddened and excoriated sur- 



308 DISEASES OF THE SKIN. 

Face, over which then' is reformation of the epidermal layer. 
Gangrenous complications are rare. 

Between the thirteenth and fourteenth days, desiccation be- 
gins, and is usually completed within from ten days to a fort- 
night afterward ; the pustules rupture, and the exuded pus con- 
cretes into yellowish and brownish, rarely blackish ertists, or 
the latter are formed by th<> desiccation of the entire envelope 
and contents. The pulse usually at the same time diminishes 
in frequency; a secondary defervescence occurs; the tumefac- 
tion of the integument decreases; and at times the peculiarly 
characteristic and often intolerably fetid odor of the patient is 
less perceptibly exhaled. In from four to six weeks, the course 
of the disease is completed. The immediate traces of the erup- 
tion are purplish and violaceous pigmentations, which slowly 
disappear. When cicatrices result, they are slightly depressed, 
dead-white, lustrous, usually symmetrical in disposition, and 
most distinct upon the surfaces exposed to the light and air, as 
the face. Though persistent, they are rendered somewhat less 
deforming in the process of years. When closely set together, 
they produce a characteristic ridged and corded appearance, due 
to the elevation of narrow hands of unallccted integument be- 
tween the depressed surfaces of scars. 

The several departures from the pronounced type of the dis- 
ease, described above, present variations differing widely from 
the most benignant forms. Brief reference only can be made to 
these. 

Authorities differ respecting the nature of the disease known 
as varicella, or chicken-pox, and particularly with regard to 
the question of its relations to variola. My own convictions 
lead me to assent in part only to the doctrine held upon this point 
by Hebra and Kaposi, who recognize it as an exceedingly mild 
form of smallpox. Without attempting to present in these pages 
the arguments pro and con, which might here be urged, it will 
suffice to refer to the objection which will most readily be 
aroused by the proposition thus enunciated. That objection will 
naturally be based upon the mildness of the symptoms which 
characterize chicken-pox. The usual response is that every 
physician of large experience has seen cases of unquestioned 
varioloid much less severe than a typical case of varicella. The 
latter often leaves indelible cicatrices. I have seen varioloid in 
the course of which not more than one dozen papules appeared, 
all vanishing without the production of vesiculation. Hebra 
recognized three types of variola; first, that which lasted but a 
fortnight, or even less time, which lie termed varicella ; second, 
that concluded in three or four weeks, whether occurring after 
vaccination or not, which lie termed varioloid; third, that 
enduring for more than one month, true variola. 

In varicella, without and altera fever of moderate grade, which 
may last for from a few hours to three or four days, there is usually 



THE EXANTHEMATA. 399 

complete defervescence and the coincident appearance of a few 
rosy macules or papules similar to those seen in variola. These 
rapidly become vesicular, and the vesicles are peculiar in being 
quite superficial, often phlyctenular in character, and either 
slightly or not umbilicated. In the latter case, they rarely pre- 
sent the well-marked puckered and "fluted" appearance of the 
variolous lesions. Their contents become lactescent rather than 
puriform ; usually desiccate on the third day in light-colored 
superficial crusts, presenting the " stuck-on" appearance described 
as characteristic of Fox's impetigo contagiosa; and usually fall 
on the sixth day. The general health is rarely seriously involved. 
The cicatrices in severe cases may he indelible. I have studied 
this disease in hospital, as it spread freely among vaccinated 
children when variola was raging side by side among the unpro- 
tected. No intelligent man to-day claims absolute protection 
from variola after vaccination. Valuable as that protection is, 
a recognition of the purely relative character of the immunity 
it confers cannot be safely disregarded. 

Varioloid, whether occurring after vaccination or not, is an- 
other modified form of the disease. With it should be classed 
all those forms of the disorder occurring in the human subject 
and described by authors under the titles, " swine-pox," " horn- 
pox," etc. In these cases, there may be severe prodromic fever 
and a scantily developed exanthem ; mild fever, abundant ex- 
anthem and rapid involution of lesions; abortion of the latter 
in any of their several stages from papule to crust; absence of 
secondary fever; transmission of the disease in a mild or miti- 
gated form, from one individual to another, so that an entire 
community, vaccinated and unvaccinated alike, may suffer from 
an epidemic disease of this moderate grade without the occur- 
rence among them of a single case of typical variola. This has 
been the experience of several small towns in the West, during 
the late variolous epidemic which visited this country. At the 
same time it is scarcely necessary to add that the patient with 
varioloid, especially during an epidemic, may transmit to the 
unprotected a malignant form of the disease. 

Much more formidable, viewed from every standpoint, is 
hemorrhagic variola, fortunately rare and too often confounded 
in the past with "black measles." When cutaneous hemor- 
rhages occur during the course of smallpox, they do not neces- 
sarily indicate that the case is one of this so-called varioliform 
purpura, since these may be accidents of the pathological pro- 
cess. In this malignant form of the disease, against whose 
ravages vaccination seems to present no barrier, the prodromic 
stage is followed by a deep purplish redness of the surface which 
is characterized by pin-head to split-pea sized, firm, closely set, 
papular lesions, suggesting the occurrence of measles in a pecu- 
liarly severe form. The febrile, nervous, and other symptoms 
of the disease are proportionately intense. Ecchymoses appear 



4 00 DISEASES OF THE SKIN*. 

upon tlio conjunctival membrane. Gradually the color of the 
exautbem, which at first disappeared under pressure, refuses to 
thus yield, and assumes h bluish-black shade. Ecchymotic 
patches may be intermingled with these, rapidly spreading to 
palm sized and larger areas. The mucous surfaces share in these 
colors, being also infiltrated with effused blood, and the muco- 
cutaneous orifices are crust-covered and exhale an extreme fetor. 
Blood may escape from the bowels, bladder, mouth, and vagina. 
Signs of grave systemic and visceral complications are always 
present. Vesiculation, pustulation,and the typical transforma- 
tions of the variolous lesions are all wanting. In the few eases 
observed by me, death lias always speedily supervened, either 
from shock, coma, hemorrhagic infarction of the lungs, or rapid 
exhaustion. Intermediate forms between haemorrhagie and true 
variola are described, in which the pustules occurring in the 
latter form of the disease merely fill with blood in consequence 
of accidents possessing merely a local significance. 

The confluent is another severe form of variola, less malignant, 
however, than that just described. It is characterized by inten- 
sity of the prodromic fever which often scarcely abates with the 
appearance of the exanthem. The latter is developed in deeply 
implanted, firm papules, closely set together, succeeded by vesi- 
cles and pustules, which, as they enlarge, full)- occupy the entire 
surface of the integument, and accomplish a perfect coalescence. 
In well-marked cases there is scarcely a, pin-head sized area of the 
entire surface of the body which is not invaded. The tissues 
become enormously cedematous ; the deformity of the face renders 
the features indistinguishable. Hemorrhagic pustules and even 
patches of a gangrenous pulp may be intermingled with the 
sheets of suppurating surface. Phonation, respiration, and deg- 
lutition are proportionately impeded or absolutely subverted by 
the tumefaction and suppuration of the mucous membranes of 
the respiratory and gastro intestinal tracts. When the patient 
survives till the stage of desiccation is reached, the body presents 
an aspect as repulsive as that ever displayed by a living being. 
A thick, brownish, or blackish-brown mask envelops the swol- 
len head, trunk, and limbs, and the odor exhaled from the body 
is intolerably repulsive. All the systemic phenomena are pro- 
portionately grave, and accompanied by one or more of the 
complications of the malady, pneumonia, pleuro-pneumonia, 
albuminuria, diarrhoea, various motor and sensory paralyses, 
subcutaneous furuncles, and abscesses. The eyes may suffer 
from pustular and ulcerative changes in the conjunctiva, cornea, 
and deeper tissues, with resulting inflammation of every grade 
to panophthalmia, and resulting loss of vision. Often the 
patients, with surprising powers of resistance, will survive till 
extensive sheets of crusts have fallen from the surface, and 
then perish slowly in a typhoid condition with low remittent 
or continuous fever. Every such case does not, however, con- 



THE EXANTHEMATA. 



401 



elude fatally. I have seen children rally from the severest form 
of confluent variola, and enjoy afterward a vigor which illus- 
trates well the wonderful recuperative energy of the natural 
forces under the most adverse circumstances. 

Variola is always produced as the result of mediate or imme- 
diate contagion. It is a disease which is both contagious and 




Vertical section of pustule at the beginning of pustulation. a, umbilication at the site of an 
excretory canal ; b, reticulum within tho epidermis ; e, reticulum of smaller meshes containing 
lymph and pus globules. (After Rindtfeiseh.) 

F)£r. 40. 




--;?' 



■if-STv-' 



Vertical section of one-half of an undeveloped pustule, n, old epidermis ; &, epithelia of rete 
above the alveoli ; c, new formed epidermis ; d, alveoli filled with pus globules ; g, flattened 
and infiltrated papilla lying beneath the pustule (After Auspitz and Basch.) 



infectious, being transmissible by volatile emanations from the 
victims of the disease. It is also artificially inoculable. When 

26 



402 DISEA8E8 OF THI SKIN. 

transmitted by the latter process, its period of incubation is 
Bomewhat shortened, and often ita successive manifestations 
become then less formidable. The history of inoculated human 
variola lias, however, received but little attention during the 
last decade, in which the practice has been properly forbidden 
by law. The disease is, to a certain extent, transmissible from 
man to the lower animal-, and the reverse. It attacks individ- 
uals of both sexes and ages, including the foetus in utero, which 
may be ushered at an untimely hour into the world, macerated 
or recently dead, and covered with the lesions of variola. The 
disease in the larger cities is decidedly more frequent in winter 
than in summer, possibly because in the colder months, the 
opportunities are greater for spreading the contagion in arti- 
ficially heated dwellings where numbers of individuals are 
crowded together. Islanders long unvisited by an epidemic, 
and unprotected by vaccination, may suffer equally in the sum- 
mer season. 

The pathological anatomy of the variolous exanthem has been 
most carefully studied by Ileitzmann in this country; and I 
append the results in his own language and in full, as an 
abridgment would fail to enable the reader to follow the dif- 
ferent steps in the process. 1 

"First, the epithelial layer, termed rete mucosum. appears slightly thickened 
in cif en inscribed spots ; the swelling is due to a coarse granulation of the epi- 
thelia themselves. This mar.-'' granulation is produced by an increase of living 
matter within the protoplasmic bodies, evidently through an augmented afflux 
of nourishing material in the stage of hyperemia. The points of intersection 
of the network of living matter, formerly so called granules, become enlarged, 
many cf tin- nuclei shining and solid, and at the same time the threads traversing 
the cement substance, the formerly so-called "thorns," become thickened. The 
underlying papillae are slightly enlarged in all diameters, partly owing to a dila- 
tation and engorgemenl of their capillary bloodvessels, partly through a peculiar 
change in the bundles of the connective tissue and the protoplasmic bodies 
between them. The latter look slightly enlarged, and in many instances coarsely 
granular, the former are partly transformed into protoplasm. In other words, 
where before there were present bundles built up by a glue-giving basis substance, 
at present the reticulum of the living matter, formerly hidden in t he relatively 
solid basis substance, through a liquefaction or dissolution of this substance, 
became visible again. No other proof of the presence of an exudation in this 
stage is obtainable except the liquefaction of the gluey basis substance. This 
Btage of inflammation is termed "papular." Next, in the midst of the papule, 
on one or on several spots, the exudation make- its appearance; the outer or 
epidennal layer at no time participates in the morbid process. In some epithelia 
we notice an enlargement of the meshes of the living reticulum, the latter is first 
stretched, afterward lorn apart, the granules being now suspended in the liquid 
exudation. Where there were present epithelia before, a small, irregular cavity 
is visible. If several BUch cavities had formed in a papule through a continu- 
ously increased accumulate f the exudation and destruction of the epithelia, 

the separating layer.- of the epithelia become compressed and produce septa, 
traversing the cavities. Such septa greatly vary in number and width. The 
neighboring epithelia look very coarsely granular. Many of them have lost the 
inclosing cement substance, and are thus transformed into protoplasmic clusters, 

' Proceed. Amer. Derm. Assn., 3d Ann. Meeting, Chic. Med. Journ. and 
Exam., Oct. is?;). 



THE EXANTHEMATA. 403 

in which, through a considerable increase of the living- matter, new shining lumps 
of different size have appeared still in continuity with the neighboring reticulum 
by means of delicate threads, the so-called endogenous formation of new elements. 
The result of this process is the formation of an irregular cavity in the midst of 
the greatly widened rete mucosum, traversed by septa of compressed epithelia; 
filled with an exudation in which there are suspended numerous delicate gran- 
ules, generally termed coagulated albumen, and a varying amount of irregular 
threads in the shape of a felt-work, the coagulated fibrin. Scanty protoplasmic 
bodies are suspended in the exudation also, perhaps remnants of the destroyed 
epithelia, perhaps immigrated inflammatory or colorless blood-corpuscles." 

"In this condition of the rete mucosum also, the underlying connective tissue 
exhibits considerable changes. The papillae have disappeared, evidently through 
the pressure from above. The transformation of the connective tissue into proto- 
plasm has advanced, .in some instances to such a degree, that the uppermost 
layer of the derma are replaced by numerous indifferent, or medullary, or inflam- 
matory elements, as a rule clustered together. All these elements, however, are 
in interrupted connection with each other through delicate threads of living 
matter, fully analogous to those of the epithelia, and thus the inflamed tissue, 
though reduced to its medullary condition, still represents a tissue. The stage 
of the disease in which the changes just described have taken place, is known 
as the vesicular stage of smallpox." 

"Lastly, pus-corpuscles appear in the cavity within the rete mucosum; they 
doubtless arise in their main mass from the epithelia traversing and bounding 
the cavity. Through the increase of living matter in a large number of epithelia, 
shining lumps appear, first homogeneous looking, afterward through the inter- 
mediate stage of vacuolation transformed into nucleated protoplasmic bodies 
with a fully developed reticulum of living matter — the pus-corpuscles. The 
main sources of pus-corpuscles therefore, are the epithelia themselves, the endo- 
■genous formation. How many of the pus-corpuscles have appeared through an 
immigration from below, from the inflamed connective tissue or from the blood- 
vessels, nobody can tell. The immigration is a sensible hypothesis only, without 
direct proof or foundation, while the endogenous formation can be directly traced 
in all its stages. The pus-corpuscles look coarsely granular, viz., are supplied 
with a large amount of living matter on the points of intersection of the living 
reticulum in persons of a good strong constitution ; on the contrary, they are 
finely granular, that is, scantily provided with living matter, in persons of a 
weak, so-called scrofulous or tuberculous constitution, or in persons debilitated 
by different acute or chronic diseases. In the former instance, the pus is thick 
and yellow ; in the latter instance, watery, serous, and pale. The subjacent con- 
nective tissue in many instances does not advance beyond its reduction into a 
medullary tissue. In some cases, however, the newly appeared and newly formed 
medullary elements, which produce the infiltration of the derma in a varying 
depth, are also torn asunder, and thus represent pus-corpuscles, which commingle 
with the pus sprung from the epithelia, and share in the formation of the abscess." 

"This stage of inflammation is known by the term pustular stage of small- 
pox, and represents the typical termination of the whole process. The pustule 
either bursts or its contents dry and produce the crust. So long as the inflamed 
derma remains in the condition of medullary tissue, so long, therefore, as the 
medullary or inflammatory elements remain connected with each other, the 
reformation of a glue-giving basis substance in the shape of bundles of fibrous 
connective tissue will be accomplished, without the formation of a scar. If, on 
the contrary, a part of the connective tissue has been transformed into pus, and 
thus completely destroyed, the result will be a cicatrix. Mere epithelial suppu- 
ration heals without, suppuration of the connective tissue always with, the forma- 
tion of a scar. The pigmentation of the skin, so common after smallpox, is due 
to the imbibition by the reticulum of living matter of the epithelia, of the color- 
ing matter of the red blood-corpuscles ; or by changes of directly extravasated 
red blood-corpuscles, both in the rete mucosum and derma. Such extravasations 
occur in all severe cases of smallpox, in the highest degree, of course, in htemor- 
rha«ic variola." 



404 DISK ASKS OF Til K SKIN. 

The difficulty attending the diagnosis of variola in its pro- 
droraic and earliest eruptive stages, from rubeola, lias been 
already mentioned. I believe that the general demand upon 
the physician for an exact and definite diagnosis of every ease 
before its typical development, is founded upon an erroneous 
conception of possibilities; and that the sooner this is generally 
recognized, the better for all concerned. A delay of even a few 
hours will often verify or remove a suspicion, and I am confident 
thai I have seen fully as much mortification on the part of the 
physician and damage to the best interests of the patient, result 
from an error in the one direction as in the other. The widest 
course in every doubtful case is to admit the doubt and to fre- 
quently visit the patient for the purpose of observing the devel- 
opment of the disease till that doubt is removed. Typical cases 
of variola are recognized with ease from the character of the 
symptoms presented. Syphilis and acne are always distinguished 
by the absence of fever and their relative chronicity. Two cases 
of suddenly occurring medicamentous acneiform rash, have come 
under my observation during the past winter, where a diagnosis 
of variola had been previously made. In each, the absence of a 
prodromic stage and the subjective sensation excited, were suffi- 
cient to point to the nature of the disease when considered in 
connection with the peculiar character of the lesions. 

The treatment of variola should in general be limited to the 
indications presented in each case. No remedies can be employed 
which have the least power to abort the disease. Kaposi calls 
attention to the striking fact in this connection, that in syphilis, 
for many of whose manifestations mercury is a specific, we 
tind a disease whose second incubative period is measured by 
weeks, and yet neither by excision of its initial sclerosis nor by 
mercurials can the subsequent manifestations of the disease be 
completely prevented. Certainly no specifics are recognized as 
of value in variola. The patient should be kept in a relatively 
darkened room with an abundant supply of fresh air of a uni- 
form temperature; and antiseptic solutions should be constantly 
at hand into which all the ejecta of the patient are immediately 
received. He should be given ice when this is grateful to the 
palate, cool water ad libitum, and his strength should be sedu- 
lously supported by a liquid animal diet. The body may be 
sponged with or bathed in cool or tepid water, as often as is 
grateful to the patient. In severe or confluent cases, the constant 
immersion of the body in the continuous warm-bath as practised 
in Vienna, is followed by the most brilliant results in hastening 
the desiccation and fall of the crusts and the subsequent repair. 
A bath of this character given for merely two or three hours in 
the day, is often of great value. With and without these exter- 
nal measures, gargles of chlorate of potash, myrrh, honey, or 
carbolic acid, will be found acceptable to the mouth and palate. 
Indeed the constant attention of an efficient nurse bestowing 



THE EXANTHEMATA. 405 

assiduous care upon the mouth, skin, and eyes, may be regarded 
as an essential part of all sound treatment. 

As regards the prevention of pitting it may be remarked, that 
no measures of a therapeutic character will prevent the occur- 
rence of a distinct cicatrix whenever pus has eroded or other- 
wise destroyed the integrity of the papillary layer of the corium. 
Every effort, therefore, should be exerted to prevent the exten- 
sion of the suppurative process to the true skin. The following 
are measures which have approved themselves to me as of practi- 
cal value: first, the sick room should be moderately darkened, 
and yet amply provided with fresh air ; second, a solution of the 
hyposulphite of sodium (Squibb's is superior to the ordinary 
preparations in the market) should be administered night and 
day in the dose of from fifteen to twenty grains (1.-1.3) every 
three or four hours. I have certainly seen the variolous lesions 
pursue a milder course under this internal treatment, and even, 
in cases, the vesicles shrivel before pustulation was fairly begun. 
Third, the skin of the face should be anointed with a bland fatty 
substance such as vaseline, almond oil, or fresh lard, and over 
this may be laid silk-enveloped compresses, dipped in tepid and 
weak solutions of carbolic or boracic acid, or thymol. I prefer 
the anointing of the surface before the application of the lotion, 
but when more grateful to the patient, the skin may be constantly 
moistened with the aqueous lotion alone. Here, again, the as- 
siduous attention of the nurse is a matter of importance. I have 
never employed the powder of iodoform topically in these cases, 
but believe that it might be often so used with advantage. 

The edges of the eyelids should be daily anointed with freshly 
prepared cold cream. Puncture of the cornea may be required 
for the relief of hypopion. Diarrhoea and other symptoms of 
visceral derangement should be relieved by appropriate medica- 
tion. As a rule, the administration of narcotics for the relief of 
pain is objectionable. Throughout all, the strength of the suf- 
ferer should be supported by a generous use of animal broths or 
milk; and in .typhoid conditions a judicious employment of 
stimulants may be necessary. 

The prognosis of variola is largelj 7 dependent upon the degree 
of protection conferred by previous vaccination. This aside, the 
age and vigor of the patient, the presence or absence of an epi- 
demic of severe or mild type, the extent of the eruption, and the 
character of the surroundings of the patient, are elements of 
prime importance. Very young and aged subjects, women preg- 
nant or in the puerperal state, and, as Hebra has shown, those 
who have suffered from a previous attack of the same disorder, 
are all unfavorably related to the final result. Confluent and 
hemorrhagic forms of the disease are, naturally, the gravest. 
Unmitigated variola is, under the most favorable circumstances,- 
one of the great scourges of humanity ; and as such will probably 
always destroy a frightful proportion of its victims. At the 



406 DISEASES OF THE SKIX. 

Bame time, tlie conscientious physician needs to be impressed 
-with the tact, that often under the most discouraging circum- 
stances, the patient, disfigured to the greatest extent by an en- 
velope of blackened crust, and in a state of extreme physical 
prostration, with many of his bodily functions almost completely 
suspended, may often, even in the midst of apparently desperate 
peril, be won back to life and vigor. The assiduous attentions 
of a gentle nurse, guided by the inspiring presence and counsels 
of a physician who is himself fearless of the malady, will often 
achieve this result. Upon the latter point, it is interesting to 
note, that physicians in active practice who do not hesitate t<> ex- 
pose themselves freely to the disease in the discharge of the du- 
ties of their profession, rarely sutler in their own persons. In 
the course of four epidemics, during which I have had the oppor- 
tunity of observing the relations between many physicians and 
their patients, 1 have never known one of the former to he 
stricken down in the actual performance of his sacred office 
among the victims of the pest. 

Vaccinia in Man. 

The limits of these pages forbid a discussion of the interesting 
questions which concern the relations of cow-pox as it occurs 
spontaneously in the milch-cow, to human variola. A careful 
collation of the results ohtained by the large number of vaccini- 
culturists of later days, renders it clear that it is a matter of great 
difficulty to transmit variola from man to the heifer; that where 
this rare result is obtained, the lymph derived from the lesions 
on the udder or belly of the latter is liable to produce variola 
when retransmitted to man; and that spontaneous cow-pox 
alone seems to furnish a lymph which is safely inoculable in 
generations to the human race. 

Of greater importance is it to note here, that either by arm to 
arm vaccination, as was formerly extensively practised, or by the 
use of the animal virus, which lias of late been well-nigh exclu- 
sively employed in this country, there has been conferred upon 
millions of human beings a degree of protection against variola 
whose value is beyond estimate. In both methods, the lymph 
is derived originally from the female of the bovine race, prefer- 
ably in the puerperal state; and its sources are the vesicular le- 
sions of vaccinia spontaneously arising or artificially cultivated 
about the teats, udder, and adjacent, parts. The introduction of 
this lymph into the skin of the human subject, is termed vacci- 
nation. 

The simple operation of vaccination is performed in many 
ways, but that which especially commends itself to the prudent 
man is the method which eliminates to the largest extent the 
possibility of transmitting any other contagious disease than the 
one intended. With this object in view, no better instrument 



THE EXANTHEMATA. 407 

can be devised than a clean needle, one which has not been pre- 
viously employed tor any purpose. The skin of the part selected 
for vaccination being subjected to slight tension by the left hand, 
the vaccinator should scratch or scrape off the epidermis with 
the needle, held in the right, by a series of parallel and crossed 
strokes, so as to make three or four superficial erosions, at a dis- 
tance of three or more inches apart. Each of these multiplex 
wounds should have the size of the little-finger nail, and. should 
in no case bleed, but merely ooze with serum slightly tinged 
with blood. At such points the lymph is to be thoroughly and 
slowly rubbed in, whether it be suppplied in a dry form upon 
ivory points which have been dipped in the serum oozing from 
vaccine lesions upon the heifer, or be a fluid obtained by crush- 
ing and dissolving in water the crust taken from the similar 
lesions on the arm of a child previously unprotected and recently 
vaccinated. In Public Charities, where, for the most part, such 
procedures are practicable, I have found it sufficient to dip a 
needle into the lymph flowing from the arm of the vaccinifer 
and to plunge it, thus charged, once or twice into the part se- 
lected for the operation. 

Between the third and fourth days after a successful vaccina- 
tion of the unprotected, a light reddish, pin-head sized papule 
rises at each inoculated point. Between the fifth and sixth 
days, it becomes transformed into a translucent, well-distended, 
occasionally umbilicated vesicle. This, when single, may attain 
the size of the finger-nail. Springing from the multiplex abra- 
sions described above, a minute papule usually forms at each 
point of intersection of the crossed lines produced by the scratch- 
ing with the needle, and the subsequent vesicles coalesce, form- 
ing thus a compound lesion of rather peculiar aspect. It appears 
often as a small coin-sized plaque, elevated to the extent of a 
line or more beyond the general level, with a rim formed of nu- 
merous discrete or confluent vesicles, which in either case are 
closely set together. The compound plaque seems to develop 
afterward as a single lesion, its centre being depressed. After 
■the ninth day, the fluid becomes opalescent, and desiccates in a 
reddish-brown crust, which, examined in section by a good light 
after it is completely dried, exhibits a smooth, homogeneous, 
shining appearance, with a color having the shade of amber. 

Fully as important as any of these metamorphoses of this 
lesion, is its rosy-reddish areola, in the absence of which some 
authorities declare that there is not proper protection. It com- 
pletely encircles the compound vesicle in the form of a halo 
having a diameter of several inches, the tissue it invades being 
often slightly tumid. When the pathological process in the 
focus of this areola is intensified, either as the result of the irri- 
tant character of the virus, or from extrinsic causes (undue ex- 
ertion, of the vaccinated part), the areola may spread extensively 
down the arm, or over the thigh or leg, and eventually cover a 



40S DISEASES OF THE SKIN'. 

dense, brawny, and deeply reddened integument. Dermatitis, 
erysipelas, and severe grades of inflammation of the subcutaneous 
tissues, may for similar reasons complicate the process, which 
may terminate by central sloughinsr, ulceration, slow repair, and 
the production of an atypical cicat rix. Ordinarily, the subjective 
phenomena arc limited to a mild or annoying itching of the 
vaccinated surface; in other cases, severe burning pain, a feeling 
of tension, and even sympathetic fever may be aroused. 

The acme of a successful vaccination is usually attained be- 
tween the tenth and the fourteenth days, after which the symp- 
toms of the disorder gradually subside, the crust falling, if un- 
disturbed, in the course of the ensuing week. When "animal*' 
virus is employed, the duration of each of these stages of the 
disease is usually somewhat prolonged. 

The cicatrix, at first slightly reddened or pigmented, gradually 
assumes the dead white appearance of scars in general. When 
typical, it is slightly depressed, circular, not irregular, nor de- 
formed by ridges, cords, or bands, and "foveolated," exhibiting a 
seriesof peripheral pits or depressions, each of which represents the 
site of a former minute vesicle of simple type. I am strongly 
disposed to believe that the degree of protection is based in part 
upon the multiplicity of typical cicatrices, and, having never 
chanced to ^ee a variolous patient with four such traces of suc- 
cessful vaccination upon the person, am largely prejudiced in 
favor of the English method of producing multiple scars. 

The complications of vaccination are due, first, to the character 
of the virus employed; second, to the character of the soil in 
which it is implanted; and third, to the external accidents to 
which the vaccine lesion is subjected. Respecting the first of 
these sources, I know of no contagious disease which may be 
transmitted by vaccination, save syphilis. When this accident 
occurs, it may be due either to the fact of syphilis in the vacci- 
nifer, or to the use of instruments soiled with infectious secre- 
tions. It is both asserted and denied, that the lymph from a 
typical vaccine vesicle in a syphilitic vaccinifer, will necessarily 
transmit syphilis, if it be accidentally commingled with either 
blood or the products of inflammation at the base of the pock. 
The demonstration of any such fact requires a mass of evidence 
exceedingly difficult to collect, inasmuch as the stage and intensity 
of the disease in the vaccinifer, are elements which cannot, be 
ignored in a decision of the question. When thus transmitted, 
it will be remembered that the vaccine lesion may complete its 
career during the incubative period of the initial sclerosis, whose 
existence at the site of vaccination is commonly declared later 
by induration, ulceration, pigmentation, and axillary adenopathy. 
The occurrence of a generalized syphiloderm before the chancre 
of vaccination is completely healed, is often the first symptom 
to arouse suspicion. Those further interested in the subject 
should study the cases collected and admirably illustrated by 



THE EXANTHEMATA. 409 

Mr. Jonathan Hutchinson, 1 of London. It should be added, that 
the popular impression regarding the frequency of this accident 
is greatly erroneous. During my entire experience in this city, 
I have treated no less than nine physicians for extra-genital 
chancre of the fingers and eyelids, acquired during the dis- 
charge of their professional duties, while I have met with but a 
single unquestioned case of syphilis transmitted by vaccination. 
This occurred in a negro infant, who had a typical initial scle- 
rosis of the arm following vaccination, with axillary adenopathy, 
and a subsequent characteristic generalized exanthem. In all 
such cases, the possibility that the syphilis might be hereditary, 
and its symptoms simply coincident in point of time with those 
of vaccinia, should not be forgotten. 

Exceedingly dangerous is that virus, however good its early 
character, in which decomposition or putrefactive changes have 
occurred after exposure, in a liquid form, to the action of 
heat and the atmosphere. Vaccination with lymph thus changed 
has been rapidly followed by fatal results after the production 
of septicaemia or pyasmia. 

Complications of vaccinia, due to the character or predisposi- 
tion of the tissues in which the virus is introduced by the vac- 
cinator, are usually ascribed by the ignorant or prejudiced to 
the causes just considered. Post hoc ergo propter hoc, is the sole 
logic of the uninformed. In this way almost all other ills of 
the human family have been in turn ascribed to " impurities" 
and "humors" introduced by vaccination. The language and 
arguments used in support of these positions have been as ex- 
travagant as they were unreasonable, and have borne fruit in the 
refusal of many physicians of repute to perform vaccination, and 
thereafter to assume the responsibility of all the subsequent ail- 
ments of the vaccinated. The cutaneous symptoms which may 
thus be awakened, are numerous. It will be remembered that 
the contents of the typical vaccine vesicle are auto-inoculable, 
and that thus the scratching of young patients may produce an 
abundant crop of typical or torn vesicles Upon the arms, legs, 
thighs, hands, and fingers. In this connection, the reader is 
referred to the chapter on impetigo contagiosa, whose pathology 
is thus for the most part explained. But vaccination may also 
awaken in the patient, as explained above, a latent syphilis, as 
also a list of cutaneous disorders not contagious in character. 
Thus an erythema (roseola vaccinia, vaccinola, etc.), eczema in 
many of its forms, and other exudative processes may be first 
aroused in the integument by the turbulence of a successful vac- 
cination. I have seen several instances of typical psoriasis which 
first appeared in the young after the same harmless operation. 
Viewing the immense number of vaccinations annually per- 
formed throughout the world, the wonder is, not that such coin- 

1 Illustrations of Clinical Surgery, Phila., 1875. 



410 DISEASES OF THE SKIN*. 

cidences occasionally occur, but that they arc not more frequently 
observed and recorded. 1 

Lastly, the com plications of vaccinia due to external accidents 
of the lesi<m, arc usually inflammatory in character. The ex- 
cessive use of the vaccinated arm in labor, and of the vaccinated 
leg in walking, standing, and other exertion, may induce, as 
indicated above, every grade of dermatitis, and even ulcerative 
changes in the site of the inoculation as a result of the inten- 
sity of the process. For these accidents, rest is essential, with 
the free use of a dusting-powder over the inflamed surface. In 
exaggerated cases, lotions of lead-water and opium may be em- 
ployed. These conditions are usually relieved without difficulty 
as soon as the part is put at rest. The atypical scar which re- 
sults, seems to lie in such cases as protective as others, if only 
the accident have occurred to a typically progressing lesion with 
distinctly perfect areola. Vaccine cicatrices are to he distin- 
guished in anomalous situations from maculae atrophica, the 
scars of syphilis, and of other scar-leaving disorders. 

Erysipelas. 

Deriv. lfvS?o;, red ; 7rix*a. the skin. 
Erysipelas is an acute and specific inflammation of the skin and subcutaneous 
tissue, characterized by diffuse, shining redness, pain, swelling, and elevated 
temperature of the affected part, terminating in desquamation, and usually 
accompanied by fever. 

Symjitomatology. — The disease is usually preceded by a pro- 
dromic period of malaise, lasting for twenty-four hours or less, 
which may be ushered in by one or several chills followed by 
febrile symptoms. The latter are accompanied by anorexia and 
often by vomiting with general depression and headache. 

The eruptive symptoms are generally first displayed at a given 
point, from which the disease progresses. It is commonly first 
noticed in a nut- or egg-sized patch, the integument of which 
is tumid, slightly elevated, irregular in contour, distinctly cir- 
cumscribed, and presents a rosy or crimson-red color with a pecu- 
liarly smooth and characteristic shining or glazed appearance. 
The sensations awakened may be those of moderate pruritus, 
pain, heat, or burning. To the touch, it is tender, moderately 
firm, and perceptibly hotter than normal. The color fades under 
pressure to a yellowish-white. 

In typical cases, the erysipelatous blush and swelling spread 
over an area which may be of the size of the palm, or may even 
cover the surface of an entire limb or region of the body. In 

1 An interesting paper on vaccinal eruptions was read by Dr. Gustav Beh- 
rend before the Dermatological section of the International Medical Congress 
in London, August 5, 1881. (See a translation of his paper bv Dr. Alexander, 
Arch, of Derm., vol. vii., No. 4, 1881, p. 383.) 



ERYSIPELAS. 411 

cases of moderate grade, the inflammation attains a maximum 
of extent and severity within a week, remains apparently un- 
altered for a day or more, and then begins to diminish, with 
amelioration of all the concomitant symptoms. The fever which 
often precedes the eruption, continues unabated during its pro- 
gress, the temperature rising to 105° or 106° F., with nocturnal 
exacerbation, cephalic and lumbar pain, dryness of the tongue, 
gastric distress, and occasionally delirium. As involution of the 
disorder is accomplished, the redness is replaced by the brown- 
ish, bluish-red, and dirty-white shades often seen after the disap- 
pearance of erythema multiforme, the epidermis filially desqua- 
mating in various degrees according to the extent of the pre- 
ceding inflammation. 

In other cases, where the exudation of serum beneath the 
epidermis has been rapid, the latter is raised in the form of 
vesicles, pustules, or bullse, more often the latter; and, precisely 
as in the severe forms of dermatitis calorica, with which ery- 
sipelas presents a certain analogy, gangrene of the skin may 
result in the part affected. This is particularly apt to follow 
the disorder when it attacks the seat of surgical wounds and 
injuries. 

Erysipelas ambulans is a term used to describe that form of 
the affection in which the erysipelatous blush, after involving 
a given area, spreads with greater or less rapidity to the parts 
in the vicinage, either by direct extension and uniform advance- 
ment in one direction, of the tumid and distinctly circumscribed 
border; or by linear, digital, or irregular prolongations radiat- 
ing from the inflammatory focus. As the blush and swelling 
advance in one direction, there is usually correspondingly rapid 
disappearance on the other. At other times, the disease, while 
extending to a new area and abandoning the old, is relighted in 
the latter, and thus an irregularly involved and irregularly ex- 
tending erysipelatous surface presents for weeks the varying 
phenomena of the disease. In yet other cases again, chiefly 
those in which there has been a history of traumatism, a long 
erysipelatous linear streak or band may spread from the site of 
the traumatism in one direction or another, suggesting the in- 
durated lines observed in lymphangitis. In severe cases, the 
febrile, nervous, and other symptoms are grave, including coma, 
delirium, meningitis, and the signs of serious involvement of 
the lungs, pericardium, pleura, and bowels. Metastatic ab- 
scesses may also occur in the cutaneous and subcutaneous tis- 
sues, the joints, peritoneal cavity, and even in the viscera. 
Death may result from these complications, or from shock, ex- 
haustion, or pyaemia. 

Surgical accidents aside, the face is the most common seat of 
the disease, where it may be first seen upon one side of the nose, 
one cheek, the lips, or the eyelid. It often attacks the lobe of the 



412 DISEASES OF THE SKIN'. 

ear after the operation of piercing the lobule for the insertion of 
ear-rings in women. Thence it may extend over the whole 
face, inclusive of the mucous linings of the month and nose, 
which present a dry, tumid, and glazed appearance, suggestive 
of the symptoms displayed upon the skin. 

The inflammation may extend to the hairy parts, hut I he- 
lieve that in many cast's it exhibits a species of reluctance to 
transgress the limits there presented. I have often noticed, in 
cases of mild grade where no applications had been made to 
arrest a local progression, that the elevated border spreads sym- 
metrically to within a few lines of the male beard, or the hairs 
at the edge of the forehead, and there spontaneously rests. In 
severer grades, these limits are readily surpassed; and then as 
a rule the extension is rapid and formidable. In this way the 
entire head may become enormously swollen, suggesting to a 
casual observer that it is fully twice its normal size. The 
patient may then he greatly disfigured: his scarlet lips, swollen, 
parted, and permitting the escape of saliva; the ears, as usual 
when greatly enlarged, projecting in a marked degree from the 
side of the head; the lids, cedematous, and incapable of separa- 
tion; the face, disfigured by hullre or crusts; and the mind dis- 
ordered hy violence of the fever, or the accesses of delirium. 
When recovery ensues, the hairs are apt to fall. 

All other regions of the body may he invaded, as the vacci- 
nated arm, the leg whose skin is involved in venous varicosities, 
the scrotum or umbilicus of the infant, the genitalia of the 
newly-delivered woman, the breast of the nursing mother, and 
every surface which has heen the seat of punctured, incised, 
contused, and poisoned wounds, or other accidents of the integ- 
ument. 

Several authors describe habitually recurrent and chronic 
forms of "erysipelas," whose identity with the disease here de- 
scribed, I am utterly unable to establish. The diagnostician is 
sufficiently often consulted in cases where an erythematous ec- 
zema of the face, an acne rosacea, or a symptomatic erythema, 
is described by a patient as chronic or recurrent "erysipelas." 
The lesions, however, to which such terms are restricted by 
careful writers, are, I am inclined to believe, forms of chronic 
dermatitis, such, for example, as occasionally follow dermatitis 
calorica. I have seen several instances in which the face, or 
parts of it, were the seat of a low grade of inflammation 
with local heat, swelling, redness, considerable infiltration, and 
sonic tenderness, the part being irritable and worse after ex- 
posure to a high wind or excesses at the table. But all 
such cases have, in my experience, failed to exhibit the distinct 
imprint of erysipelas; they were not only chronic in course, but 
exceedingly indolent, lasting for years; they were unaccompa- 
nied hy fever; they were distinctly limited in all accesses of 
aggravation to the same part of the face; they were never char- 



ERYSIPELAS. 413 

acterized by a bullous efflorescence; they never completely dis- 
appeared; many occurred in the subjects of chronic alcoholism. 

Etiology. — The essential cause of erysipelas is not clear. At 
times it seems to be the result of contagion, and usually in such 
cases is septic in character and developed in severe grade. Thus 
I have seen the mother impart the disease to the child at the 
breast; and the erysipelas that may spread from patient to 
patient in the lying-in and surgical wards of a hospital, has 
made a large figure in the annals of medicine. In other cases, 
the disease without question springs into activity spontaneously, 
expends its energy upon a single individual, and, in spite of con- 
tacts of the most intimate character favorable to its transmission, 
spares all others. It is immediately produced in many cases by 
a mild or severe traumatism, the scratching of a pustule or of a 
louse-bite, or by a carious tooth. It may also complicate almost 
every one of all medical and surgical disorders, from leprosy 
and fracture of a bone, to eczema and a soft corn. Persons of 
both sexes and all ages may be affected ; but those especially 
who are debilitated by years, alcoholism, excesses of all sorts, 
cachexia, and those surrounded by wretched hygienic condi- 
tions. At times its appearance seems to depend upon climatic 
changes and the seasons of the year. 

Pathology. — The anatomical changes observed in the erysipe- 
latous skin do not, as might be anticipated on a 'priori grounds, 
furnish any clue to the apparent specificity of the disease. 
Under the microscope, the skin and subcutaneous tissues are 
seen to be infiltrated, the exudate being more serous and less 
rich in protoplasm than that observed in ordinary phlegmonous 
inflammation of the skin. The bulla? represent rapid exudation 
of this same serosity to the congested epidermis, and the eleva- 
tion of the latter in consequence. The elements of the rete and 
connective tissue are for the same reason swollen, the lymphatic 
and bloodvessels enlarged, and the cutaneous follicles engorged, 
the root sheaths of the hairs being occasionally separated, neces- 
sitating thus the temporary loss of the pilary growth. In pro- 
portion to the severity of the exudative process, pus corpuscles 
may appear and represent, for the most part, degenerative 
changes in the subcutaneous tissues resulting in abscess. 

Diagnosis. — Erysipelas is to be distinguished from the erythe- 
mata, from dermatitis of various grades, from eczema, and from 
scarlatina. As a rule, its recognition from all is readily effected, 
when the presence of the fever in erysipelas is had in view, as 
also the peculiar shining, swollen, and rosy-reddish to damask 
hue of the affected parts. The redness is never produced as in 
scarlatina by multiplicity of reddish puncta, nor is it so widely 
diffused as in that disease. Erysipelas may be at times accom- 
panied by a pruritic sensation, but the patch which it affects is 
never by any possibility scratched. By this simple test alone, 



414 DISEASES OF THE SKIN. 

one may often recognize an erysipelas of the face from an eczema 
of the same region in a child. From a chronic dermatitis with 
thickening of the affected tissues and redness of the surface, 
erysipelas is to be distinguished by its tendency to spread, by 
its acute career, by its frequent association with bullaa or vesic- 
ular lesions, and by the color, outline, and raised border of the 
affected patch. However, it must be understood that to these 
localized patches of chronic dermatitis several authors have 
given the name, chronic erysipelas, the difference between the 
views held on this point being chiefly one of terms. 

Treatment. — Upon the continent of Europe, the therapeutic 
management of erysipelas is in general limited to the employ- 
ment of such systemic and topical measures as are specially re- 
quired in each case. Quinine is administered whenever indi- 
cated by the temperature record; and the erysipelatous surface 
is either left exposed to the air, covered by dry compresses, 
moistened by cold or hot aqueous lotions, or anointed with un- 
guents, simple, mercurial or anodyne, as suggested in each case. 
Occasionally cataplasms arc applied over the inflamed surface. 
Abscesses, whether subcutaneous or connected with a carious 
tooth, are opened; the contents of all pustules evacuated; and 
crusts carefully removed. Kaposi lays stress upon freeing the 
nasal cavities of all inflammatory products, whenever the face 
is attacked. 

I confess myself to he prejudiced in favor of the method of 
treating erysipelas which has long been popularized among 
American practitioners. Internally, the muriated tincture of 
iron is administered in full doses, day and night every four 
hours, irrespective of the febrile state. When the erysipelatous 
blush has a distinctly circumscribed outline, the annular zone 
extending for an inch or more in width upon the sound and 
affected skin is either covered with the tincture of iodine, pen- 
cilled with a crayon of nitrate of silver, or painted with a satu- 
rated solution of the same salt. This is done with a view to 
limit the extension of the disease. It is true that these meas- 
ures will not always succeed, but I believe it erroneous to assert 
with some authors that they always fail. Certain it is that, 
whether effective or not in the production of the result, the 
advancing border of the disease will often fail to surpass the 
limits thus artificially described. Collodion has been employed 
for a similar purpose, and lately Darlin 1 has written in advocacy 
of the revival of this method of treating the disorder, basing its 
claim on the fact that it diminishes the temperature of the part 
thus protected, and that by the compression excited, it interferes 
with septic absorption. HeppeP recommends the painting over 
the surface of a ten per cent, solution of carbolic acid in alcohol 

1 Bull. Gen. de Ther., vol. ii., 1881, p. 239. 

2 Arch, of Derm., April, 1881. 



ERYSIPELAS. 415 

as an abortive treatment for which Braitbwaite 1 substitutes a 
similar solution of tannin. 

I have had excellent results in the local treatment of erysipe- 
las, by first attempting to limit the extension of the disease by 
the application of the tincture of iodine over a peripheral zone, 
and, secondly, by retaining over the entire surface affected, 
neatly applied compresses saturated with a solution of the hy- 
posulphite of sodium in the strength of about one drachm (4.) 
to the ounce (32.). My friend, Dr. Spencer, of the United States 
Army, informs me that in this way he has frequently seen the 
disorder upon the face entirely relieved in forty-eight hours. 

Erysipelas rarely attacks a patient in vigorous health. The 
large majority of all the subjects of the disease are either those 
who have previously suffered from manifest general ill-health, 
or who have been complaining of local ailments, trifling wounds, 
nasal catarrh, or surgical accidents. It is these precedent condi- 
tions which often demand the special attention of the physician 
or surgeon. 

Finally, there are forms of erysipelas which are remediless. 
These are usually septic in character. The scarlet blush spread- 
ing from an irreparable injury of long duration, is often the 
last protest of nature against the damage which even her final 
resort of gangrene will not avail to repair. 

Prognosis. — Under favorable circumstances, erysipelas, even of 
severe grade and extensive invasion, terminates in complete re- 
solution. Reserve should be made, however, in every case, as a 
serious complication has often transformed the simplest into the 
gravest forms of the disease. I have seen an erysipelas of mild 
grade originating in the irritation of the lobe of the ear by an 
ear-ring, transmitted to a child who died with gangrene of the 
entire mucous lining of the oral cavity. The very young, the 
cachectic, the victims of drink, the aged, the inmates of hospital 
wards depressed by other illness, and those mentally distressed by 
destitution and neglect, are particularly liable to suffer from grave 
and fatal forms of the malady. 

The patients who fill the beds in most lying-in hospitals are 
young women, either unmarried or deserted by their husbands, 
and unprovided with the necessities of life by those upon whom 
such a responsibility rests. The mental depression thus origi- 
nating in connection with the septicemic influences too common 
in all large charities, is responsible for much of the relation 
which erysipelas often seems to sustain to the puerperal state, 
as also for the appalling mortality which it may exhibit under 
these circumstances. 

1 Brit. Med. Journ., April, 1881. 



410 DISEASES OF THE SKIN. 

2. Neoplastic. 

Scrofuloderma. 

Derir. Lat. aerofa, a sow. 
Scrofuloderma is a cutaneous affection characterized by indolent hypernemic, 
exudative and degenerative changes in the skin, associated with adenopathy 
of thr contiguous lymphatic ganglia, and often with other evidences of a 
systemic vice of nutrition. 

Symptomatology. — The term scrofula, or struma, has been loug 
and loosely applied in general medicine, for the purpose of desig- 
nating a number of diseases whose real significance was unknown, 
and whose points of resemblance to each other were greatly out- 
numbered by their specific differences. The researches of the 
last twenty years have been steadily and continuously restricting 
this list, in almost every department of medicine. Many of the 
disorders once supposed to be scrofulous, are now known to be 
syphilitic. Rickets, for example, is properly recognized to-day 
as a manifestation of hereditary lues. In orthopaedic surgery, 
a number of joint affections once believed to be incontestably 
of strumous origin, are known to be producible by traumatism 
exclusively. And in dermatology, no less, a broad advance has 
been made since the day when eczema, psoriasis, and acne were 
described as evidences of scrofula. 

It should, however, be not forgotten, that there are few fast 
and hard lines in the economy of nature. The requirements of 
a scientific classification of diseases, are often too rigid for the 
phenomena both of good and ill health. It cannot be questioned 
that the scrofulous may become both eczematous and psoriasic ; 
and that struma may coexist with syphilis, lepra, and other dis- 
eases. Indeed the accumulated experience of this generation 
points to the recognition of the scrofulous state as one which is 
capable of artificial induction, and that thus a patient may 
become strumous after exhibiting all the evidences of perfect 
health. 

The coexistence of cutaneous with other diseases, proves no- 
thing as to the essential character of either, or the relation of 
the one to the other. I have at this moment in my charge two 
patients who have been psoriasic- for years, each of whom has 
lately contracted syphilis, one with the addition of a blennorrha- 
gia. The distinction between these disorders is admitted beyond 
a perad venture; and yet when the strumous patient gets eczema, 
acne, or lupus, it is difficult and often impossible to establish in 
the mind of an observer the conviction that there is no essential 
connection or relation between these disorders. 

It is oidy by comparing such cases with the multitude of 
others where no such coneomitance can be recognized, that a 
just estimate of the truth can be made. 



SCROFULODERMA. 417 

This much premised, it may be added that the term, scrofulo- 
derm, is here strictly limited to those cutaneous changes which 
occur in distinctly scrofulous subjects, and which are themselves 
stamped by the peculiar imprint of tiie disease. Billroth's de- 
scription of the scrofulous diathesis may here be recalled. By 
this term he recognized that condition in which there occurs at 
any point in the body where irritation has been induced, an 
indolent inflammation which persists after such irritation has 
ceased, which frequently terminates in suppuration and caseifi- 
cation, and which subsequently rarely pursues an hyperplastic 
career. If with this be conjoined inflammation and caseous 
infiltration of the lymphatic ganglia or of the subcutaneous 
connective tissue; amyloid degeneration of one or several of the 
viscera ; tumefaction of the belly ; chronic keratitis, ophthal- 
mia, otorrhcea, or eoryza ; a chronic arthritis (white swelling) ; 
a pasty, dirty-colored and thick, or delicate and transparent skin 
exhibiting cicatrices of old abscesses or ulcers, the general pic- 
ture of the scrofulous patient may be considered complete. 

The typical scrofuloderm is encountered about the face and 
neck, where the lymphatic glands have long been tumid and 
either dense or doughy to the touch. This condition is usually 
reached very slowly; often months and years are required for 
its production. The glands may be as small as almonds or as 
large as the closed fist. Gradually a scrofulous dermatitis ensues, 
in the skin which is superimposed. It becomes purplish and 
thinned and finally yields, giving exit to a sero-purulent fluid 
mingled with caseous matter and blood. The pus-corpuscles of 
this fluid examined under the microscope, are seen to be poor in 
protoplasm. Fistulous tracts and sinuses result, which under- 
mine and perforate the skin, resulting in the formation of a 
chronic discharge and characteristic ulcers. 

The latter are far more remarkable for their borders and bases 
than for their floors. They are usually linear, occasionally elon- 
gated and ovalish, almost never circular. As a result, their uneven 
floors, covered with pallid granulations and a Avatery pus, are 
often hidden beneath their inverted, tumid and uncolored edges: 
or the latter may be thinned, stretched over a fistulous pocket, 
and reddish or purplish in color. Their bases are usually deeply 
attached to the subcutaneous tissues, and are firm or sottish, 
never densely indurated. The resulting crusts are thin, tena- 
cious, reddish or brownish, and, like the ulcer, often linear, rarely 
bulky, never rupioid. The resulting cicatrices are corded, de- 
pressed in irregular lines or bands, and often alternate with 
equally irregular nodules (scrofulous gummata), where the degen- 
erative process has been either arrested or is still in progress. 
27 



418 DISEASES OF THE SKIN. 

The Papular Scrofuloderm (Lichen Scrofulosorum). 

This eruption, first described by Hebra, is characterized by 
its chronicity, and tlie occurrence chiefly upon the trunk, hack, 
and belly, of millet-seed to pin-head sized, firm, flat, light to 
livid red, and grouped papules. These are occasionally sur- 
mounted nt the apex by a minute scale, rarely by an equally 
Bmall pustule. The lesions arc at the onset isolated ; later, they 
tend to arrange themselves in coin-sized patches ; when evolu- 
tion is accomplished they are closely set together, the surface of 
the skin being then of a dirt}- reddish-brown color, and covered 
by thin scales which are readily detached. Often a crescentic 
outline can be determined in a group of aggregated lesions. 

The course of the eruption is slow; often the cutaneous symp- 
toms persist for months without apparent change, awakening 
little or no pruritus, and followed by involution, accompanied by 
Blight desquamation and no cicatrices. 

In ninety-nine per cent, of all cases observed in Austria, there 
was concomitance of the genera 1 symptoms of struma named 
above (submaxillary, cervical, and axillary adenopathy, perios- 
titis, ulcerative dermatitis, etc.), with frequent complications, 
such as eczema of the scrotum and acne cachecticorum. The 
disease was encountered in young strumous patients between 
the periods of infancy and puberty, never after the twentieth 
year. 

According to Kaposi, the disease consists in an exudative 
infiltration of the pilo-sebaceous follicles and the perifollicular 
tissue. Each papule represents, therefore, the orifice of a fol- 
licle, with an infiltrated perifollicular annex; and its apicial 
scale or pustule, a mass of epithelial debris, or the inflammatory 
exudate. 

The disease is readily differentiated, by the absence of itch- 
ing, from papular eczema. From the miliary papular syphilo- 
derm, it differs in that the lesions of the latter, even though 
grouped, are always individually distinct. The general symp- 
toms, however, are strikingly different in the two diseases. 
Lichen scrofulosorum cannot be confounded with the forms of 
lichen ruber. Lichen pilaris, however, in a young and lym- 
phatic patient, might readily be mistaken for the disease in 
question. 

This scrofuloderm is rare in France, and has not yet been 
recognized in this country. 

The Small Pustular Scrofuloderm. 

This eruption has been described by Duhring 1 only. In the 
three patients whose cases are reported, there were disseminated 
pin-head and small split-pea-sized, yellowish pustules, having a 

1 Trans. Am. Derm. Assn., Fourth Annual Meeting, Chicago, 1881, p. 29. 



SCROFULODERMA. 419 

firm base and purulent contents, visible on the extremities, es- 
pecially over the hands and forearms. Their course was indo- 
lent. Corneous, yellowish, or grayish-tinted crusts succeeded, 
leaving a marked "punched out" scar. Relapses occurred, the 
entire process lasting for months and years. The general symp- 
toms of struma were present in each case. The disease is to be 
distinguished from the small pustular syphiloderm, acne cachec- 
ticorum,and follicular lupus. Microscopic examinations of the 
lesions exhibited unmistakably a non-follicular origin of the 
disease. 

The Large Pustular Scrofuloderm 

is described by the same author as a rare eruption, constituted 
of large, roundish, flat pustules, with a deep-red or violaceous 
areola. A thin, fiat, brownish, and adherent crust partially or 
completely covers each lesion, after the desiccation of its yel- 
lowish contents; and beneath it is found a shallow ulcer of the 
scrofulous type. One, two, or more lesions may exist, often over 
the sternum, where they leave superficial cicatrices. There is 
concomitance of the general symptoms of struma. 

Etiology. — Scrofula is a disease of both sexes and all races, 
usually developed in early life, and either inherited or acquired. 
All causes which tend to impair the nutrition and vigor of the 
body are, to an extent at least, efficient in its development, in- 
cluding privation from sunlight, fresh air, wholesome food, exer- 
cise, and hygienic influences in general. It is common among 
prisoners, exiles, and, in this country, among negroes and 
those of mixed blood. Consanguineous marriages are said to 
result often in strumous offspring. Syphilis, in the third and 
fourth generation, is known to be pathologically distinct from 
all of its manifestations. The question of the possibility of its 
production by inoculation and its transmission in a feeble degree 
by contagion, is still unsolved, with the probabilities strongly 
against the affirmative. In many cases it is the sequence of 
other depressing medical diseases and surgical accidents. In 
other cases, especially where it is limited to the neck, and ac- 
companied merely by cervical or submaxillary adenopathy, it is 
consistent w T ith full vigor and nutrition of the body and all 
other evidences of sound health. 

Diagnosis. — The disease is to be distinguished by its general 
physiognomy from syphilis, lupus, cancer, purpura scorbutica, 
and other diseases exhibiting cachectic symptoms. The early 
age at which it is commonly developed is usually significant. 
The site of the lesions, with their characteristic ulcerations, 
crusts, and cicatrices, are also distinguishing features. 

Treatment. — The general treatment of struma demands a gen- 
erous supply of fresh air (especially that of the sea-shores abound- 
ing in kelp); a liberal animal diet, including an abundance of 



420 DISEASES OF THE SKIN. 

pure milk and cream ; and the employment of cod-liver oil, iron, 
iodine, lime, phosphorus, and similar substances internally. The 
local treatment of the disease requires the employment of poul- 
tices, lotions, stimulating unguents, and disinfecting washes, 
with such Burgical interference as is demanded by the existence 
of pus-filled pockets, sinuses, and fistulous tracts. 

Prognosis. — The disease, when skilfully managed, is amenable 
to treatment. The st ruinous patient who survives puberty will, 
if surrounded by favorable circumstances, usually show fair 
health afterward. The course of the malady is, however, 
always tedious. The prognosis may be said in general to be 
based upon the severity of the symptoms in early life. 

Tuberculosis of the Skin. 

Tuberculosis of the skin, associated with or secondary to 
tuberculous foci in underlying tissues, is occasionally encoun- 
tered. In this way, for example, in tubercular disease of the 
testis, the skin will become painful, tender, and of a livid hue, 
will become attached to the subcutaneous tissues, and finally 
yield, giving exit to a soft, caseous matter, mingled with pus. 1 
Wagner, Weber, and other authors have described similar 
changes. True tuberculosis of the skin proper, is of exceedingly 
rare occurrence. Chiari and Jarisch have, however, reported 
such cases, one in a male patient, forty-two years old, who 
had behind the left ear a reddish-yellow, crescentic, granu- 
lating ulcer, with infiltrated borders and a number of degene- 
rating miliary granulations upon the velum of the palate. Post- 
mortem, isolated, and grouped, roundish nodules were discovered, 
undergoing caseous degeneration. Spillmatr gives several in- 
stances of tuberculization of tiie skin associated with pulmonary 
phthisis. 

Two cases of tuberculosis of the skin have recently been ob- 
served at Kaposi's clinic. 3 

The patients were aged respective!}', 53 and 36 years. In one, 
there were buccal, laryngeal, and tracheal ulcerations of tuber- 
culous character, with an ulcer of the upper lip, occupying the 
entire space between the nose and the lip. The other patient 
presented a coin-sized ulcer near the left ala nasi, and others on 
the lip and adjacent gum. In one of these patients, the lungs 
were intact, and the tuberculosis of the skin was primary. The 
other died of pulmonary phthisis; but in both there was in- 
testinal tuberculosis. Microscopical examination of the cuta- 
neous lesions disclosed numerous tubercles in the corium which 
had undergone caseous degeneration. In the centre of the mass, 
disseminated miliary nodules, transparent or light-yellow in 

> Diseases of the Testis, T. B. Curling, F.R.S., London, 1878, p. 339. 

2 De la Tuberculatum du Tube Digestif, These de Paris, 1878. 

3 Deuts. Med. Zeit., Jan.1882. 



SCROFULODERMA. 421 

color, were visible in the parts which had not yet undergone 
characteristic granulation. 



There are several disorders of the skin, some of which also in- 
volve the integument with other than cutaneous tissues, whose 
nature is obscure, and with regard to whose identity there may 
be even a question. A brief reference to some of these may 
here be appended : — 

Ainhum. — This disease was first described by Dr. J. F. Da Silva 
Lima, 1 of Bahia, in Brazil. In a paper by this author, which was 
read by me before the American Dermatologieal Association, in 
1880, 2 the disease was described as affecting usually the little 
toe of the negroes resident both in Africa and Brazil. An in- 
durated ring encircled the root of the digit, which produced, 
finally, a deep, narrow, circular depression, the latter deepening 
till the toe Avas strangulated, and finally, in the course of from 
five to ten years, completely detached. Meantime, the volume 
of the digit was greatly increased by development of fatty tissue 
at the expense of the tendons, vascular elements, bones, and car- 
tilages. 

This paper was accompanied by the presentation of a toe 
affected with ainhum; and the specimen was referred to a com- 
mittee, who examined it with care, and reported the result of 
the examination by the succeeding year. The report, presented 
by Dr. Heitzmann, of New York, after giving a full description 
of the anatomical appearance of the specimen, suggested the 
probability that the constricting ring was produced artificially, 
by tying a thin ligature around the toe, which, if not continu- 
ously encircling it, was worn at least for long periods of time. 

Podelcoma. — This disease, known also as mycetoma, or the 
fungous foot of India, attacks generally the foot, though the 
hand may also be affected. The part becomes swollen, and 
covered with pea-sized boutons, or elevations, over which are dis- 
persed minute blackish granules. Each tubercle surmounts a 
sinus, from which is discharged a thin, sero-puruient fluid, con- 
taining granules, separate or aggregated in yellowish-brown, 
mulberry-like masses. The disorder has been carefully described 
by Vandyke Carter, Minas, Moore, and other surgeons of India, 
a country where the disease has been prevalent. Tilbury Fox 
presented, at different times, two specimens of the disease to the 
London Pathological Society; and it is worthy of note, that in 
England the black masses were not in every case discovered. 
Kemper 3 has reported a similar case in this country. 

1 In the Gazeta Medica du Bahia, Nov. 13 and 15, 1S67. 

2 Arch of Derm , October, 1880. 

3 Amer. Practitioner, Sept. 1876. 



422 DISEASES OF THE SKIN. 

My colleague, Prof. Charles T. Parkes, of Chicago, has re- 
cently had under observation a similar case, occurring in the 
person of a gentleman who had long been a resident of India. 
From the notes kindly furnished me, it appears that, after the 
occurrence of characteristic tubercles, an ulcer attacked the skin 
over the inner malleolus of the right ankle, and steadily in- 
creased in size and depth for a period of five years, in spite of 
all treatment. Sinuses extended deeply to the tissues beneath. 
The entire surface was covered by a peculiar, sottish, light- 
colored, flnfi'y material, corresponding to that described by several 
of the Indian observers. The general appearance of the disease 
was unlike any previously observed here. The entire surface 
was thoroughly scraped with a Simon's spoon, and dressed with 
a saturated solution of boracic acid, after which repair ensued. 

The existence of a iungus as the cause of the disease, does not 
seem to have been established. 

Perforating Ulcer of the Foot. — This disorder is well de- 
scribed by Messrs. Savory and Butlin. 1 I am inclined to believe 
that it is accounted a rare disease rather because little attention 
has been hitherto attracted to it; as its causes are sufficiently 
common. 

I have seen several cases answering the description of the 
authors named, the most typical of which was referred to me by 
the late Dr. Alexander Fisher, of Chicago. In the centre of a 
bunion, which had formed over the right first metatarsopha- 
langeal articulation of a young man, there was exposed the orifice 
of a sinus which could not be made to close. The course of the 
disease was exceedingly indolent, the parts being the seat of 
little pain. The weeping from this sinus was scanty, and it 
was not surrounded by granulations. It was more an annoyance 
at first, than a serious disease. Finally, by the aid of a fine 
probe, it was discovered that the sinus beneath led to exposed 
bone. A deep incision was made at this point, and the osseous 
surface thoroughly scraped, after which antiseptic dressings 
were applied. The sinus, however, reformed in time; and it 
became finally necessary to amputate the toe, and remove by the 
gouge a large portion of the head of the corresponding metatarsal 
hone. This operation proved successful in relieving the patient. 

The disease results from traumatism of the bursas covering 
the smaller articulations of the foot, the products of the inflam- 
matory process being confined in the sac, externally by the 
dense tissue of the corn or bunion aided by the artificial press- 
ure of the coverings of the foot. Thus the deep sinus is formed. 
It should be treated by surgical measures. 

1 Med. Chir. Trans., vol. lxii. 1879. 



LEPRA. 423 

Synovial Lesions of the Skin. — Under this title should be de- 
scribed certain strictly cutaneous lesions which possess some im- 
portance from a diagnostic point of view. I have had the oppor- 
tunity of observing these in several individuals, where the exact 
nature of the disorder had not been understood. They occur in 
the form of wart-like projections from the skin, pseudo-vesicles, 
and bullae, always over the site of bursse connected with tendons 
traversing the small articulations of the hand and toot. They 
are seen over the metatarso-phalangeal articulations; and in the 
hand most frequently over the dorsal face of the articulation be- 
tween the distal and adjacent phalanges of the index and thumb. 
The first form is that of a roundish, corneous, pea-sized wart with 
a yellowish centre, of long duration, and usualljMnsensitive, un- 
less roughly handled. When punctured, a syrupy, yellowish, 
or grnmous fluid exudes, and continues to form after repeated 
puncture. Split-pea sized vesicles, and bullae as large as a silver 
fifty-cent piece, often exceedingly painful, are also seen, especi- 
ally upon the feet, with simply an epidermic roof-wall. Each 
contains the same thickened, yellowish, or whitish fluid, occa- 
sionally mingled with masses like sago grains. In every case 
the contents of the lesion are supplied by a synovial bursa be- 
neath the skin, with which the lesion is either directly con- 
nected ; or in communication by a short sinus. The treatment 
requires the complete excision or destruction of the secreting 
cyst-wall. 

Lepra. 

Deriv. Gr. xs^of, scaly. 

Lepra is a chronic, endemic, constitutional disease, capable of involving all of 
the organs and tissues of the body, whose cutaneous characteristics are : 
pigment alterations, disordered or abolished sensation, tubercles, or other cir- 
cumscribed or diffuse infiltrations, bullae, ulcers, cicatrices, atrophies, destruc- 
tion of deep tissues, loss of the appendages of the skin, and the ultimate pro- 
duction of a cachexia which usually terminates fatally. 

Symptomatology. — Leprosy has also been termed elephantiasis 
giuecorum and lepra arabum. In whatever form it may be 
ultimately manifested, its appearance is usually preceded by the 
prodromic symptoms generally recognized as the precursors of 
severe constitutional disease. These are: anorexia; chills, al- 
ternating with mild or severe febrile attacks; depression; gastro- 
intestinal disturbance; and insomnia. Their duration is ex- 
ceedingly variable; in some cases, patients will remember that 
these or similar symptoms preceded for years the earliest out- 
break of the disease. In yet others, but a few weeks' interval 
occurs between the prodromic and successive stages of the dis- 
ease. It is worthy of note that the character of the former fur- 
nishes no clue to the severity and type of the latter. 



424 



DISEASES OF THE SKIN. 



The earlier cutaneous lesions of leprosy are tubercular, macu- 
lar, or bullous. These may he coincident or successive, or one 
or two of these types may so far predominate that another may 
be either altogether wanting, or possess, in the general patho- 
logical history, but a trifling significance. It has thus been 
customary to make an entirely artificial distinction between 
cases of leprosy, by assigning them to three varieties, tubercu- 
lar, macular, and anaesthetic. It will be understood, then, in 
separately considering these three forms, that the distinction 
between them is useful simply for the purposes of classification; 
that mixed eases of the disease occur which it would be diffi- 
cult to assign to either variety exclusively; and that each 
merely represents a predominance of certain lesions at one path- 
ological epoch. It should be noted also that the symptoms of 
leprosy are particularly remarkable for their polymorphism, a 
wide variation often existing between the character of two or 
more lesions which at any given moment are apparent. This is 
largely owing to the fact that leprosy is a general and constitu- 
tional disorder, the cutaneous symptoms of which are simply its 
surface markings. 

Lepra Tuberosa. 

Tubercular leprosy commonly begins in the skin with macu- 
lar lesions. These are bean to tomato-sized, reddish, brownish, 

Fig. 41. 




%i>A 



i,,,, 



lss,.n and Boeck.) 



or bronze patches; roundish, ovalish, or irregular in contour; 
and occurring upon the face, trunk, or extremities. The skin 



LEPRA. 425 

covering these is either smooth and shining as if oiled ; or mode- 
rately infiltrated and elevated. 

After a period ranging in duration from weeks to years, 
tubercles rise from these maculations, varying in size from a 
pea to a nut, though they may be as large as a tomato. They 
are yellowish, reddish, brown, or bronzed in color, often shining 
as if varnished or oiled, covered with a soft, natural, or slightly 
desquamating epidermis, roundish, or quite irregular in contour, 
and either isolated or grouped. Numbers of very small and ill 
determined nodules may often be recognized by careful exami- 
nation of the skin in the vicinity of those fully developed. 
They may be either cutaneous or subcutaneous in situation, and 
softish or quite firm to the touch. 

The site of predilection of leprous tubercles, is the face; and 
their massing in great numbers upon this region produces the 
characteristic deformity of the countenance which has given to 
the disease one of its names, leontiasis (face of a lion). In such 
faces, the tubercles are ranged in parallel series above the brows, 
down the nose, over the cheeks, the lips, and the chin. In con- 
sequence of the infiltration and development of the lesions, the 
brows deeply overhang the globes of the eyes, the lids become 
affected with a partial ptosis, the lips pout, and the ears are so 
studded with tubercular masses as to project from the side of the 
head." The trunk and extremities, including the palmar and 
plantar surfaces, are then usually to a less degree involved. Oc- 
casionally, indeed, with extensive development, of tubercles upon 
the face and ears, there may not be more than from five to fifty 
upon the rest of the body, and these either widely dispersed and 
isolated, or agglomerated in a single, hard, flat, elevated plaque 
of infiltration upon the elbow or thigh. 

With these cutaneous lesions there is 
often involvement, of the mucous sur- 
faces, especially the velum palati and 
larynx. In the case of a leper affected 
with the tubercular form of the disease 
whom I exhibited at the clinic in 1879, 1 
there was very marked gruffness and 
hoarseness of the voice, and the larynx 
and velum were studded with pin-head 
to pea-sized ashen-hued tubercles. Oth- 
ers may form Upon the Conjunctiva and Larynx of patient affected with 

the Schneiderian membrane. lep ™ tuberculosa - ( The ™^'» 

mi 11 i • case ) 

these tubercles may degenerate into 
ulcers; or undergo resorption and disappear, leaving in their 
place pigmented atrophic depressions ; or lose their shape in 
consequence of partial resorption. I have thus seen a large 

1 Chic. Med. Jour, and Exam , Dec. 1879, with cut showing laryngoscopic 
appearance of larynx. 




426 



DISEASES OF THE SKIN* 



plaque flatten centrally till an annular disk was left to indicate 
its former site. 

It should he borne in mind, however, that the course of the 
disease is exceedingly slow, and that years may elapse before 
these several changes are accomplished. The disease, indeed, 
often appears to he quiescent for months at a time, after which 
with the occurrence of fever, acute or subacute manifestations 



Fig. 43. 



Fig. 44. 



I 




Larynges of lepers afiected with lepra tuberculosa. (Elsberg's 



appear and a relatively rapid progress is made toward its fatal 
conclusion. Long before the latter is reached there are usually, 
in tubercular leprosy, intermingled symptoms of anaesthetic type, 
such as the occurrence of bullae or of anaesthetic patches with 
and without pigmentation. Toward the last, the mutilations 
effected by the disease may result (lepra mutilans). Phalanges 
of the fingers or toes, whole digits, an entire hand or foot may 
then become partially or wholly detached by ulcerative, atrophic 
or other degenerations of skin, bones, and ligaments, hastened 
or not by intercurrent attacks of lymphangitis, erysipelas, sep- 
ticaemia, and irritative fever. 

The stadium of this type of the disease may extend through 
ten or even more years. After its full development, the pecu- 
liarly dejected countenance of the leper with his leonine facies 
and general appearance of cachexia, are highly characteristic. 

Lepra maculosa. 
This form of the disease is chiefly distinguished, as its name 
implies, by its macular lesions. These have the general charac- 
ter of those described as preceding the appearance of the leprous 
tubercles. They are diffuse or circumscribed, roundish or irreg- 
ularly shaped, and in color yellowish, brownish or bronzed, often 
shining or glazed. They may be infiltrated or not; and in the 
former case, be slightly raised from, or on a level with, the adja- 
cent tissues. At times, they appear as lardaceous deposits in the 
skin, whitish, reddish, or even blackish in color, with a telangi- 
ectasie border. These patches are usually at first hyperaesthetic, 
but finally become quite insensitive, so that a lancet can be thrust 
deeply into them without producing the slightest sensation. 



LEPRA. 427 

The pigment variations in macular lepra are noticeable. At 
times, a distinctly anaesthetic patch may be readily limited both 
by its lack of sensation and of normal color; at others, either 
symptom may fail to correspond with the area of involvement 
defined by the other. Thus a palm to platter-sized, texturally 
unaltered area over the thigh or belly, may suggest a vitiligo 
by its relatively slight pigmentation and its distinct contour, 
beyond which are sepia- to deep-chocolate tints, gradually fading 
toward some adjacent and similarly involved patch. Yet this 
area will often differ materially from that of vitiligo in other 
respects. Every inch of. the former may be totally insensitive 
to the prick of the lancet, and be moreover of a dull, tawny, 
yellowish, or parchment-like hue, never having the peculiar 
milky white tinge of vitiligo. Again, this anaesthesia may ex- 
tend widely beyond the line traced by the pigment anomaly, or 
even within the latter vary, islets of skin capable of perceiving 
sensation, being in cases here and there discernible. 

Lepra ansesthetica. 

This variety may be, as has been described, commingled in its 
symptoms with each of the others. With and without these, 
however, there is commonly noted first an eruption of bullae, 
bean to large nut-sized, with a roof-wall constituted of the entire 
thickness of the epidermis, filled with a clear tinted or blood- 
mixed serum, occurring usually upon the extremities. The cic- 
atrices which follow these are atrophic patches, often far greater 
in extent than the base of the original bulla; whitish, shining, 
glazed, or better described as of a tint suggesting the hue of 
mica; circular in outline, forming also the dumb-bell figure by 
coalescence or juxtaposition. These are always anaesthetic; and 
may coexist with macular and anaesthetic patches upon the trunk 
or other portions of the body. Neither those of the one class 
nor of the other, are, however, disposed over the surface of the 
body in lines, bands, or curves corresponding to the distribution 
of the cutaneous nerves. The greatest irregularity is displa}^ed; 
asymmetry is the rule. Occasionally, however, the ulnar and 
other nerves accessible to the touch, are recognized to be tumid, 
tender, insensitive, or as rigid as indurated cords. General atro- 
phic cutaneous symptoms follow these; the skin becomes dry 
and harsh ; there is manifest^ little or no sebaceous product ; 
the sweat is scanty; the muscles atrophy; the hairs fall; the 
lymphatic ganglia enlarge ; the skin of the face seems tightly 
stretched over the bones. As a result of deforming atrophy of the 
lids, epiphora and consequent orbicular changes ensue; and the 
parted lips permit constant escape of saliva. The fingers are half 
drawn into the palm of the hand ; the nails are distorted ; and, 
lastly, ulceration occurs. The ulcers are irregular, ovalish, round- 
ish, linear; covered with thin, blackish and flattened, tenacious, 



428 DISEASES OF THE SKIN. 

never rnpioid, crusts: their bases are soft, their floors covered 
with a pultaceoua debris often mixed with blood; the whole 
often insensitive to every foreign body and external application. 
Lastly, the symptoms of lepra mutilans often occur, digits, or 
portions of the carpus, metacarpus, or corresponding parts of the 
loot being detached from the body. 

Death may ensue at any time during the course of the disease 
from septicaemia, exhaustion, or any of the intercurrent affec- 
tions to -which a patient in such condition is particularly dis- 
posed. Thus a leper was lately accidentally choked to death in 
San Francisco by some perversion of the function of deglutition. 
The disease, however, in this form is said to last from eighteen 
to twenty years, and is thus less rapidly fatal than the tubercu- 
lar variety. 

Etiology. — The causes of leprosy are at this day apparently as 
far beyond recognition as before the date of the extensive re- 
searches, and the accumulation of the large volume of literature 
which the interest of the subject has awakened. 

According to Schmidt, whose papers 1 relating to the general 
theme are among the most valuable of recent communications, 
no less than one hundred and eighty-three volumes and 
papers have appeared under this title since the year 1866, in- 
cluding the report of the Royal College of Physicians of Lon- 
don, in 1867, which represents the facts collaborated from two 
hundred and fifty private reports. 

The geographical distribution of the disease is widely ex- 
tended." It" exists in the interior and throughout the seaboard 
regions of Africa, including Egypt; in Arabia, Syria, Persia, 
China, Japan, and India; in the Islands of the Mediterranean, 
Black, Caspian, and China Seas, of the Indian Ocean, and of the 
Australian Archipelago; in Norway and Sweden, Iceland, Rus- 
sia, Turkey in Europe, Spain, France, Portugal, Greece, Italy, 
and sporadically in Germany, England, and the smaller Euro- 
pean States; in Northern, Central, and South America, and the 
West India Islands. In our own country, special attention has 
been directed to the subject by the existence of the disease in 
an endemic form in the Sandwich Islands, with which the 
Pacific States sustain close commercial relations: by its occur- 
rence among the Chinese immigrants in San Francisco and 
other portions of California; by cases reported from New Or- 
leans by Bruns, 2 Bemiss, 3 Jones, 4 and Solomon, 5 and by vari- 
ous reports of sporadic cases observed in Minnesota, Maryland, 
Illinois, Nebraska, New York, and other States of the Union, by 



1 1. A Contribution to the Pathological Anatomy of Leprosy, Archi' 
[edicine, Dec. 1881. 2. Is the Bacillus Leprce a Reality or a Fiction V 



ives of 
Medicine, Dec. 1881. 2. Is the Bacillus Leprce a Reality or a Fiction V Chi- 
cago Med. Journ. and Exam., May, 1882. 

z Arch, of Med., Dec. 1881. 3 N. O. Med. and Surg. Journ., April, 1880. 

4 Ibid., March, 1878. 5 Trans. Louis. State Med. Assn., 1879. 



LEPRA. 429 

Gronvold, Hoegh, Bendeke, Robe, Piffard, Elsberg, Atkinson, 
myself, and others, collected by the Committee on Statistics of 
the American Dermatological Association, and presented to 
that and other bodies in special papers. Drs. White and 
Graham, of the same Committee, have also contributed to the 
history of the colony of lepers which has long existed in 
Tracadie, in the province of New Brunswick. 

With this wide geographical distribution, it is yet clear that 
the disease exists endemieally in certain countries, and also in 
certain regions of the same country, with greater frequency than 
in others. All attempts, however, to connect its origin with 
malaria, with a residence near inundated sea marshes, with the 
ingestion of a diet consisting largely of fish, or of a diet from 
which salt has been largely excluded, have failed of any recog- 
nized success. It is true that probably the larger number of all 
living lepers are those who have been poorly fed, and otherwise 
subjected to the most insalubrious of influences, but the disease 
also attacks, though more rarely, persons whose social position 
and hygienic surroundings are of the best. It occurs in both 
sexes and at all ages; and, despite all efforts to show the con- 
trary, bears no relation to syphilis. Lepers become, however, 
syphilitic if infected with the disease, precisely as they may and 
do acquire variola, varicella, rubeola, erysipelas, and phthisis. 
The heredity also of leprosy remains to-day as incapable of 
demonstration by facts, as its so-called inoculability and con- 
tagiousness. The doctrines held upon the latter point have 
been greatly reinforced by the general popular acquaintance 
with the Hebrew Scriptures, which are often interpreted as 
showing that the disease among the Jews in Palestine, was re- 
garded by them as contagious and so treated. The careful 
student of these writings will, however, be convinced that this 
interpretation is erroneous. The leprosy of the book of Leviti- 
cus not only includes lepra, as that term is understood to-day, 
but also psoriasis, scabies, and other cutaneous affections. The 
leper in the eye of the Mosaic law, was ceremonially unclean, 
and capable of communicating only a ceremonial uncleanness. 
Several of the narratives contained in these Books bear witness 
to the fact that the Oriental leper was occasionally seen doing 
service in the court of kings, and even in personal communica- 
tion and contact with officers of high rank. 

The latest theory relative to the etiology of the disease has 
been advanced and advocated bv Hansen (1870, 1874, 1880), 
Carter (1875), Neisser (1879), Cornil (1881), Hillairet and 
Gauche (1881), and in our own country by Bermann, of Balti- 
more. These observers have recognized parasitic organisms in 
various tissues of the bodies of patients living and dead of lep- 
rosy; and have concluded that the bacteria (bacillus lepra?) thus 
discovered, were the causes of the disease. I would refer those 
who are further interested in this subject, to the masterly paper 



430 DISEASES OF THE SKIX. 

by Schmidt, 1 in which flic errors of these writers have been im- 
partially and conclusively shown. I might add that I have per- 
sonally and carefully examined the elegantly mounted sections 
prepared both by Schmidt and Bermann, and can fully corrobo- 
rate the conclusions reached by the former. In some sections, 
bacteria are unquestionably present, whether introduced by the 
vehicle of fluids used for staining or by an avenue opened by an 
ulcerating lesion, it is difficult to determine. Their occurrence 
in the blood, an essential point in the demonstration of their etio- 
logical importance, has been recognized solely by HiJIairet and 
Gauche; but the observations of these gentlemen have been too 
imperfect to justify their recognition as the basis of a scientific 
fact. Briefly, the bacillus of lepra is identical with the bacteria 
which form in an infusion of ha}-; living germs, indeed, and 
visible occasionally in sections of leprous tissue, but without any 
significance whatever in the etiology of the disease. 

This somewhat extended glance at the theories propounded 
in explanation of the origin of leprosy, is necessitated by the 
vast amount of discussion and writing which the theme has 
awakened. It may be justly concluded with the statement by 
which it was introduced, the causes of leprosy are absolutely 
unknown. 

Pathology. — The histological element of leprosy is represented 
by a new growth of round, oval, uni- or bipolar or otherwise 
irregularly contoured bodies. These originate either in the con- 
nective tissue of the skin, mucous membranes, adventitia of the 
vessels or nerve beneath, or are derived, as Schmidt has shown, 
from the epithelium, endothelium, and even the fat elements of 
the affected tissue. These are single, or grouped in a collection 
of two, a dozen, or even more individuals; such groups being 
arranged in elongated, oval, pyramidal, or ellipsoidal forms. 
Making its earliest appearance in the reticular portions of the 
corium, the growth may progress thence externally toward the 
papillary layer and epidermis, or downward to the subcutaneous 
tissue, or develop in both directions simultaneously. Gradually 
there is invasion of the pilary and sebaceous follicles, the sudo- 
riparous glands being apparently less frequently involved. In 
the same way, the fat and vascular elements undergo a trans- 
formation into the newly-formed elements. The viscera are also 
changed by the pathological process, particularly the liver, kid- 
neys, and spleen. By degeneration of these elements, atrophy, 
ulceration, and eventually the mutilating deformities of the 
advanced stages of the disease are induced. 

The result of the researches of Schmidt are in accord with 

1 Loc. cit. It is interesting to note in this connection that, since this page 
was written, the same author has demonstrated that both the forms presented by 
the bacillus lepra 1 ami the bacillus tuberculosis can be artificially produced in 
leprous and tuberculous tissues, by the formation of rod-like crystals of margaric 
acid. 



LEPRA. 431 

the observations of Virehow, relative to the peculiar changes in 
the nerves. Explaining thus the hyperaesthetic, anaesthetic, 
and possibly also the pigment alterations so characteristic of the 
malady, proliferating elements are recognized by this author 
in the ependyma of the central canal of the spinal medulla, in 
the posterior commissure, and about the fourth ventricle. The 
nerve-fibres in the posterior and other white columns, had under- 
gone degeneration, as also those of the medulla oblongata, the 
corpus striatum and the Gasserian ganglion, the latter being in 
one case, small, indurated, and its connective-tissue sheath thick- 
ened and adherent to the dura mater. The sheaths of the larger 
nervous trunks have been also seen to be involved, and the peri- 
and endo-neurium atrophied as a result of previous infiltration, 
the axis-cylinders often, however, persistent. 

The relatively slow progress of the disease is explained by 
the exceedingly slow development of the new formed material ; 
its inaptitude, for long periods of time, to undergo retrogressive 
metamorphosis; and its tendency, for similar periods, to invade 
the skin exclusively, thus sparing for years the viscera whose 
ultimate involvement necessitates cachexia and a fatal issue. 

Diagnosis. — In well-marked cases the recognition of leprosy 
is simple. In its prodromic periods, no suspicion of its existence 
would be awakened in countries where the disease was not 
endemic. 

From sj-philis, which is also a disease whose lesions are poly- 
morphic in character, lepra can be distinguished by its much 
greater chronicity ; its larger and brownish-yellow, glazed 
tubercles ; its frequent hyperaesthetic and anaesthetic symptoms ; 
its bullous lesions, rare in acquired syphilis; the far more ex- 
tended areas of its erythematous macules; its blackish crusts, 
lacking the rupioid aspect of those in syphilis; its leathery, 
mica-tinted cicatrices; and the characteristic leonine facies of 
its tubercular forms. 

Morphcea and vitiligo are both unattended by constitutional 
changes, and more particularly by hyperaesthetic or anaesthetic 
symptoms in the affected patches. The atrophic and often 
deeply pigmented condition of the skin in the final stages of 
pityriasis rubra, associated with the emaciation and febrile con- 
dition of the patient, might mislead for a time the observer 
who had not a full history of the case. Multiple myelomata 
(sarcomata, of Virehow), especially upon the face, are followed 
by much more rapid degeneration and a fatal result. 

Treatment. — No remedies are know T n to have a directly cura- 
tive effect in leprosy. As a consequence, the treatment of the 
disease is that suggested to the intelligent practitioner by the 
indications in each case. The most important of the latter, is 
an immediate change of residence and climate; the adoption of 
a highly nutritious diet; and the exhibition of roborant reme- 
dies, including steel, quinine, cod-liver oil, and often the mode- 



432 DISEASES OF THE SKIN. 

rate use of wines and malt liquors. Mercury, arsenic, the iodine 
compounds, the oil of cashew nut, gurjuu balsam, and chaul- 
moogra oil, internally and externally, have all been employed 
with varying Buccess by different practitioners, but an unpre- 
judiced review of the maximum of results thus obtained, will 
establish the conviction that no one of the remedies named may 
l>e regarded as in any sense possessing a controlling influence 
over the disease. Most of them have been employed by skilful 
physicians, sufficiently wise to enforce simultaneously the most 
generous tonic regimen, thus clouding with some doubt a belief 
in the part played by the medicament in the production of t lie 
result. In the case of a leper and his little daughter in the State 
of Nebraska, who were treated by me for some time with chaul- 
moogra oil, very marked benefit was noticeable in the course of 
a few months, a result I am quite willing to credit, in this 
instance, to the salubrious surroundings of a farm in the country. 

Baths are of great value in all these cases, and may be medi- 
cated with any desirable substance. It should not be forgotten 
in the local treatment of leprous tubercles, ulcers, and other 
lesions, that however foreign the disease may he to this climate 
and this country, the simple principles, dermatologieal and sur- 
gical, by which one is governed in ordinary cases, are here not 
to be forgotten. Carbolic acid, bland unguents, inunctions, and 
local stimulants of the skin, are as useful, when properly applied, 
to the leper, as to the syphilitic, the cancerous, and the scorbutic. 

Prognosis. — The future of the leper is indeed dark. The dis- 
ease is malignant in character, and, however protracted, a fatal 
result is usually inevitable. Still, with a change of climate and 
improved hygienic conditions, much can be accomplished. There 
can be no question but that the Scandinavian lepers who have 
removed to this country, have been greatly benefited by the 
change. Such indeed was the opinion of the late eminent Profes- 
sor Bceck, who during his useful career visited Minnesota, and 
there studied the history of eighteen leprous immigrants who had 
come from his own country. He believed, in fact, that the 
change in some cases would work a complete arrest of the dis- 
ease. I am inclined to the belief, after a somewhat careful study 
of the history of leprosy in America, that such a favorable re- 
sult could be anticipated with a more reasonable probability 
after residence in the North western States, than in any other 
portion of this country. 

Pellagra. 

This disease has recently attracted attention by its extensive 
ravages in Lombardy and the continuous provinces, including 
a portion of Southern France and Spain. It is also termed risi- 
pola lombarda (Lombardy erysipelas), lombardy leprosy, and 
among the common people, la rosa. It is a constitutional en- 



PELLAGRA. 433 

cleraic disorder, accompanied by an exantliem, which justifies its 
brief consideration in this connection. 

The first symptoms of the disease are prodromic, and charac- 
terized by marked fatigue, malaise, and occasionally by febrile 
symptoms. Soon the face, neck, chest, and backs of the hands 
and forearms (when exposed to the sun) sire affected with an 
erythema of a dull lurid hue, which may be accompanied by 
desquamation, occurring in successive years, chiefly in the sum- 
mer season, often fading, at times with desquamation, in the fall. 
After frequent relapses, the skin becomes of a dark olive-brown, 
bluish-red, or deeply-pigmented and bronzed hue, and general 
exfoliation of the epidermis follows in lar^e flakes. Simulta- 
neously, an extraordinary degree of muscular feebleness is no- 
ticed ; the skin becomes pruritic or hyperassthetie ; and a sensa- 
tion of chilliness is induced, similar to that observed in general 
exfoliative dermatitis. As in that disease also, the fingers 
gradually become semi-flexed into the palm, and gastro-intestinal 
derangements supervene, accompanied by a furred tongue, inap- 
petence, colicky pains, and diarrhoea. Disorders of the nervous 
system are betrayed by melancholia, disturbed vision, idiocy, 
convulsions, and symptoms of meningitis. Post-mortem, pachy- 
meningitis, with induration, atrophy, and other secondary 
changes of the brain and cord, have been observed. 

Pellagra has been very generally believed to originate in the 
use, as an article of diet, ot' maize which was either invaded by 
the fungus of ergot, or had developed other deleterious substance 
after its reduction to a coarse powder. While this cannot be said 
to have been fully disproved, it is certain that individuals have 
suffered from the disease who have never partaken of maize, and 
also those who have not been specially exposed to the action of 
the sun, which in some cases seems to have served as the exciting 
cause of the disease. The exact etiology of the malady should 
rather be traced by the statesman and politico-economist. The 
wretchedness, poverty, poor food, and hopeless moral and social 
condition of the inhabitants of the pellagrous districts, many of 
them toiling under a burning sun, half-starved, emaciated, and 
despairing, should explain largely the symptoms of the scourge 
which afflicts them. Certainly there is here to be found a very 
satisfactory explanation of the failure of several writers on the 
subject to describe a disease of such typical aspect and career as 
to command recognition of its distinct and special identity. 
Subjected to the influences named above, a large population 
could scarcely fail to exhibit a wide range of differences in the 
symptoms by which was expressed their physical protest against 
the severe ordeal to which they were alike exposed. 

The treatment is that manifestly indicated in the facts set 
forth above. 
28 



434 DISEASES OF THE SKIN. 

Frambcesia. 

Tins disorder is encountered chiefly among the negroes resi- 
dent along the African coasts, in the West Indies, and in South 
America, where it is also known as yaws and pian. By Alihert, 
it was termed mycosis frambcesioides. It is said to be charac- 
terized at first by the occurrence of brownish-red, pin-head to 
pea-sized, flat maculae. In these, one or more yellowish or whitish 
puncta become visible, which gradually develop into roundish 
papules or tubercles, resembling pea-sized and larger pustules of 
yellowish-red color. When the integument which covers these 
gives way, a fetid, sero-purulent fluid exudes; and a dirty-yel- 
lowish, spongy mass projects from the rent, and enlarges subse- 
quently, till it appears as a yellowish-red, crusted vegetation, an 
inch or more in diameter. This may degenerate into an offen- 
sive ulcer, whose destructive processes are accompanied by pro- 
gressive emaciation and systemic disturbance. Instead of this 
retrogressive metamorphosis, the tubercle may shrivel into a 
dark-colored, crusted, and withered excrescence, yielding a fetid 
and ichorous discharge. The eruption occurs upon tiie face, 
neck, extremities, ano-genital region, and, rarely, upon the trunk. 

The lesions are seldom the seat of subjective sensation. They 
have been considered contagious, and not susceptible of trans- 
mission by heredity. The course of the disease usually extends 
through several months. It is also said to occur at all ages and 
in both sexes, one attack conferring immunity against another. 
The contributions to the literature of this subject have been 
made chiefly by Drs. Milroy and Imray, of Dominica, and Dr. 
Bowerbank, of Jamaica. 

There is, however, strong reason to discredit the doctrine 
that frambcesia is a disease $ui generis. Certain it is that in 
both syphilitic and non-syphilitic subjects, who have never 
visited the countries where it is claimed that the disease is en- 
demic, similar symptoms have been recognized and described. 
An interesting case of frambcesioid lesions in a syphilitic woman 
is reported by De Amicis;' and I have personally treated three 
patients whose lesions corresponded very closely to those de- 
scribed above, no one of whom was syphilitic. It can be readily 
understood that a vegetation occurring upon the filthy skin 
of an unwashed negro in the tropics, might assume features 
which would be scarcely recognized as classical, in the clientele 
of most practitioners in this country. 

It is safest at present to regard the term frambcesia as largely 
descriptive in scope, and as including certain papillomatous and 
other vegetations projecting from the surface of the body as a 
result of filth, syphilis, tropical temperatures, and possibly of 
other unfavorable agencies operating upon the skin of a negro. 
A sufficient commentary upon these considerations is afforded 

' Cf. a translation of his paper by himself in the Archives of Derm., October, 
1879, p 39. 



SYPHI LODERM A . 435 

by the admission of the West India surgeons, that mercury and 
the iodide of potassium are regarded as specifics for the disease 
as it exists in those islands; and that cleanliness is of prime 
importance. 

The Parangi Disease of Ceylon. 

Kynsey 1 has recently presented a report upon the nature of 
the disease which is thus designated in Ce}don, where it pre- 
vails. It appears to present mixed, features of syphilis, land 
scurvy, yaws, pellagra, lupus, leprosy, scrofula, and less severe 
disorders, existing as an endemic in certain provinces of the 
island. It is clear, from the description of the symptoms re- 
corded, that the nature of the disease has not yet been recognized. 

Syphiloderma. 

Syphilis is a chronic infections disease, transmitted by heredity, or by the me- 
dium of intoxicated blood or morbid secretions, capable of involving in its 
course any one of the organs and tissues of the body, whose manifestations 
in the skin are termed syphilodermata. 

Syphilis has been described by one writer as an "imitator" 
of other diseases. Whatever exception it is proper to take to 
the doctrine implied by such a term, it is necessary to clearly 
understand of the manifestations of the disease that they are 
protean in character, and may occur in every organ and tis- 
sue of the body. These manifestations are both like and un- 
like the symptoms of non-syphilitic disease of such organs and 
tissues. It would be, therefore, more in accordance with facts 
to describe syphilis as a special mode of disease. Its phenomena 
differ from other pathological phenomena, chiefly in the syphilitic 
modality with which they are impressed. In syphilis there is 
no evidence that any material foreign to animal bodies has been 
introduced from without, but only after infection there is a dif- 
ferent behavior of the living matter or protoplasm of which the 
body is constituted. Its mode is thenceforward temporarily 
changed, as regards the processes of disease. Hence the import- 
ance of recognizing this modality in relation to disease of the 
skin, and of ascertaining the limits within which this influence 
is both originated and exhausted. 

The skin manifestations of syphilis are of common occur- 
rence; numerous as to their forms, and of the greatest import- 
ance from the diagnostic standpoint. 

As in syphilis of other organs, that of the skin is betrayed in 
symptoms like and unlike those of non-syphilitic affections. 
The study of these differences is here also a study of the syphi- 
litic mode of disease. In a treatise of this scope and within 
these limits, it will be proper to describe only those evidences of 
the syphilitic process to be recognized in the integument. The 

1 Med. Press, March 15. 1882, p. 281. 



436 DISEASES OF THE SKIN. 

initial lesion of the malady occurring either on the mucous 
membrane or integument, requires brief consideration. 

Chancre. 

A chancre is that modification of the sound or pathologically 
altered skin or mucous membrane, preceded by a period of incu- 
bation, characterized by sclerosis, and accompanied by adeno- 
pathy, which constitutes the initial lesion of inevitable syphilis. 

Chancres usually appear upon or about the genital organs 
simply because those organs are most often exposed to the dis- 
ease. They may. however, occur upon any portion of the sur- 
face of the body. 

They appear after a period of incubation, an interval of time 
between the date of exposure to the disease and the manifesta- 
tion of its first symptom. This period averages in length 
twenty-one days, and may extend from ten days to two months 
and even more. 

The chancrous modification may, as stated above, involve the 
normal or pathologically altered skin or mucous membrane. 
Upon previously sound surfaces, chancres may appear, after the 
incubative period, as maculae, papules, tubercles, erosions, fissures 
or ulcers, each of which, at some period of its histoiy, is charac- 
terized by a peculiar hardness of the tissues about and beneath 
the lesion, this condition being known as the initial sclerosis. 
These symptoms vary according to the location of the lesion, 
and the friction or other external treatment to which it has 
been accidentally subjected. Generally it may be said, that they 
all tend to the papular type, the macule developing into that 
lesion, the tubercle being evolved from its exceptional enlarge- 
ment, the ulcer from its degeneration, and the erosions or fissures 
from the accidents of its less pronounced features. Occurring 
upon mucous or quasi-mucous surfaces, these lesions are influ- 
enced by heat, moisture and friction (labia, prepuce, etc.). Here 
the superficial erosions are usually circular in outline, are very 
slightly depressed, and rest upon delicate beds of sclerosed tis- 
sue, the so-called parchment induration. The papule is often 
represented by a macular discoloration of the membrane, tole- 
rably well circumscribed, where coarse examination would 
scarcely suggest elevation of the surface, with a sclerosis of no 
greater extent than that of the erosion with which it probably 
sustains a close relation. As a result of heat, moisture, and 
friction, however, the typically dry and scaling papule consti- 
tuting the chancre of the integument, is here rarely encountered. 
More often, the lesion is a circumscribed ulcer with clean-cut 
walls, penetrating deeply to the derma or even below it, with a 
scanty secretion and reddish floor, resting upon a split-pea sized 
mass of sclerosed tissue. Other usual forms are superficial ero- 
sions, in themselves of insignificant aspect, surmounting large 



SYPHILODERM A. 437 

nodules, tubercles, or even long linear ridges of densely sclerosed 
tissue, undergoing repair or degenerating according to the con- 
dition of the patient and the treatment to which he has been 
subjected. These erosions are usually out of all proportion to 
the size of the indurated mass upon which they rest. Such 
voluminous indurations are occasionally perforated by deep 
conical or funnel-shaped ulcerations of formidable aspect, to 
which the name " Hunterian chancre" was once applied. 

Occurring upon cutaneous or mucous surfaces where there has 
been a previous pathological condition, the syphilitic mode is 
impressed upon the symptoms significant of such previous dis- 
ease. This accident is sufficiently common, and the resulting 
lesions as different as those of different diseases. Thus a man 
or woman may be infected with syphilis at the site of an her- 
petic vesicle upon the lip or genitals, such vesicle being unbroken 
and recent, or several days ruptured ; or at the site of a balanitis; 
or of a vegetation ; or of the soft contagious sore of the genital 
region best recognized in America under the term, "chan- 
croid." Or the. inoculation may occur at the site of a trauma- 
tism, as for example where the frenum is slightly torn in coitus, 
or where the bruised knuckle of the accoucheur is exposed during 
the practice of his art. 

The induration of chancres may precede, accompany, or follow 
the lesion with which they are associated. The sclerosis may 
be short-lived, persistent or recurrent: and in this respect re- 
semble the chancre itself, which may endure for but a few days, 
or be in course of full evolution at the date of the appearance 
of the so-called secondary symptoms. 

With very rare exceptions, the ganglia in anatomical connec- 
tion with the chancre become, as a consequence, enlarged and 
specifically indurated. With genital chancres, there is usually 
double inguinal adenopathy; with labial chancres, submaxillary 
adenopathy ; with chancres of the lid, preauricular adenopathy, 
etc. The glands usually enlarge within a few days after the 
appearance of the chancre, and remain in that condition for 
several months afterward. They are indurated, on one or both 
sides of the body; are freely movable ; are unattached to sur- 
rounding tissues; are neither painful, tender, nor inflammatory; 
and hence neither terminate by suppuration nor ulceration. 

It will thus be evident that the word "chancre" is applicable 
only to certain features assumed by other lesions; and is not 
itself descriptive of a lesion differing absolutely from all others. 
It is indeed clear that there can be no particular chancre lesion, 
since in turn the macule, vesicle, pustule, papule, tubercle, ero- 
sion, vegetation, ulcer, and fissure may each become a chancre. 
Every other elementary lesion of the skin, therefore, may assume 
the chancrous features, in other words, display in its disease- 
process the modality of syphilis. These chancrous features are 
infection ; sclerosis after an incubative period ; coincident or 



438 DISEASES OF THE SKIN". 

consequent adenopathy (sclerosis of neighboring ganglia); and, 
after a second incubative period, the occurrence of the symptoms 
of general syphilis. The last named is of course an historical 
feature, unrecognizable during the greater part of the life of most 
chancres. 

Their minor features are less constant and trustworthy. Chan- 
cres of the skin are often deeply pigmented. Some are painful 
from the occurrence of inflammation. Some are injured by 
traumatism (chancres of nipple in nursing women); some, by 
irritants (caustic improperly applied); some finally are so insig- 
nificant in feature (chancre of the vagina) that even the expert 
is readily deceived in their recognition. 

With or without involution and complete disappearance of 
the chancre, the symptoms of general syphilis occur only after 
a second period of incubation. This extends usually from be- 
tween the end of the first to the end of the second month after 
the appearance of the chancre, the average being between the 
fortieth and forty fifth days. During this period the general 
condition of the patient is one which, by subjective and objective 
phenomena displays signals of the approaching distress of the 
economy. There is anaemia and even in cases, ehloro-ansemia, 
wandering pains, sub-sternal or about the articulations, a cachec- 
tic look, engorgement of the superficial and deep ganglia, occa- 
sionally a well-marked febrile process, the so-called syphilitic 
lever, and, as Bumstead has shown, a special irritability of the 
skin and mucous membranes. 

At this moment, the second period of incubation of the dis- 
ease being completed, the patient is apt for an "explosion" of 
general syphilis. Insidiously or suddenly, first noticed acci- 
dentally upon the skin beneath the clothing, or with rapid 
efflorescence over the entire surface after a hot bath, the stimulus 
of liquor, or the excitement of the dance, appear the syphilo- 
dermata, or syphilides, the skin-symptoms of syphilis. 

The Syphilodermata. 

Lesions of the skin appear in syphilitic individuals of both 
sexes, in all periods of life, and in all stages of the disease. 
They are, however, much more frequent during the first two 
years after infection, subsequent to which period the symptoms 
of the disease are more commonly betrayed in subcutaneous le- 
sions, or those which affect the viscera, the osseous, nervous, 
muscular, and vascular systems. 

General Characteristics of the Syphilodermata. — The sy- 
philodermata, like chancres, are, properly speaking, modalities 
of such symptoms as occur in diseases not syphilitic. The dis- 
tinctive difference between the papules, ulcers, and other lesions 
of syphilis and lupus for example, is a difference chiefly in their 



SYPHILODERMA. 439 

mode of evolution and involution. It is the syphilitic behavior, 
rather than the syphilitic lesion, which guides the diagnostician 
to his end. The syphilides, in short, resemble in their lesions 
most of the other diseases of the skin, and differ also in various 
degrees from each one of the latter. Hence is seen the import- 
ance of a clear recognition of their general characteristics. 

Absence of Subjective Sensation. — The eruptions produced 
by syphilis are rarely attended by itching, burning, or painful 
sensations of any sort. This is frequently a positive aid in estab- 
lishing a diagnosis, and, as a rule, is the more valuable the 
graver the lesion. Great difference, however, will be noted in 
this respect between different individuals. Occasionally consid- 
erable itching will be perceived, and syphilitic ulcers, especially 
of the leg, will be productive of considerable pain. At the same 
time, it is a common experience to find a patient quite tranquil 
as regards all subjective symptoms, covered from head to foot 
with a brilliant macular syphiloderm, or exhibiting, with the 
utmost composure, an enormous number of serpiginous ulcera- 
tions on his scalp and extremities. 

Polymorphism, multiformity of lesions, a term used to design 
nate the coincident appearance of lesions of various types upon 
one individual, is true of syphilis as of other diseases such as 
lepra and scabies. Viewing the cutaneous and other lesions of 
syphilis as a whole, this feature is strikingly significant, as it is 
possible to observe at one and the same time upon the person of 
a single infected individual, symptoms indicative of pathological 
changes in the skin, mucous membranes, hair, nails, lymphatic 
glands, and periosteum. 

To a less marked degree, this is true of the syphilodermata. 
The type of the syphilitic skin lesion is generally papular; and 
such lesions may originate from macules, enlarge into tubercles, 
or degenerate into ulcers. The simultaneous coexistence of 
several of these forms is often due, as Bumstead and Taylor have 
well shown, to their chronicity, their tendency to recurrence, 
and the changes which they undergo. 

Career. — The historical course of the syphilides suggests cer- 
tain common features. They are rarely accompanied by local 
inflammation, and with the exception of the sj^philitic fever, 
are usually unattended with pyrexia or malaise. The tolerance 
by the general economy of an extensively developed syphiloderm, 
is highly significant of the disease. Again, syphilis, though 
generally described as a chronic disease, is, judged from the 
standpoint of time merely, much more acute than several others. 
The syphilides have a distinct career, pursuing, even when un- 
treated, a natural process of evolution and involution. Few, 
save those upon the lower extremities, where the force of gravity 



440 DISEASES OF THE SKIN. 

is an important element in the fixation of all local disease, per- 
sist in unvarying type for any lengthened period of time. One 
lesion is apt to succeed another by development or degeneration; 
and many of the untreated syphilides disappear without leaviug 
relics of their existence upon the surface of the skin. In these 
last named particulars, syphilitic cutaneous manifestations are 
singularly different from lupus and carcinoma, for example, 
where the lesion is usually of one type, and persists in one loca- 
tion for a long period of time, during which thesyphilide which 
it resembles would have progressed either to much more exten- 
sive damage or permanent repair. 

Color. — There is no color peculiar to the syphilodermata, 
which may not be seen in other diseases of the skin. It is im- 
portant to recognize the fact clearly, as there are those who 
claim to diagnosticate the syphilides by their hue alone. The 
color, however, considered in connection with the other features 
of the syphilides, is highly characteristic, and often sufficient to 
enable one at a glance to identify the nature of the disease. 
These color shades are usually less brilliant than those seen 
in other cutaneous diseases, and possess less of the scarlet and 
crimson quality. They are admixtures of red, yellow, and 
brown, in various proportions, with a frequent slight preponder- 
ance of the brown. They have been compared to the color of 
raw ham and copper, terms which have been unfortunately so 
associated with the hue of the syphilides, that the non-recogni- 
tion of such peculiarity has led to many errors in diagnosis. 
Pigmentations, in various shades of chocolate, coffee, and black, 
are recognized among the syphilides both during their evolution 
and after completion of their involution. The process, as in 
eases where there has been no luetic infection, is here also due 
to increase of the pigment in the part, both with and without 
the extravasation of blood. Recent syphilitic scars are usually 
pigmented both in centre and periphery. Here also it is not so 
much the color, as the scar with the color which gives special sig- 
nificance to such lesion-relics. 

Contour. — The contour of single elementary cutaneous lesions 
in syphilis as also of a group of aggregated lesions, is usu- 
ally either circular, or has a distinct tendency to assume such 
a configuration. Thus it is common to tind outlines of patches, 
ulcers, and scars observing the curve of a segment of a circle; 
and coalescence of several such tends to produce the serpiginous 
aspect. The earlier exanthems of syphilis are usually symmetrical ; 
the latter, asymmetrical. Even the symmetrically distributed 
eruptions will at times occur in annular patches, made up of 
maeulo-papular lesions arranged in a circular or crescentic line. 
Patches of syphlitic eruption will often clear up at the centre 
and develop or spread at the circumference of a circle. 



SYPHILODERMA. 441 

Site. — ~No portion of the integument is free from the invasion 
of syphilis. It may involve at once almost the entire integu- 
ment, or spread rapidly from point to point, having covered 
finally a large area, or appear conspicuously at distant and iso- 
lated points of limited extent; or, finally, be exclusively mani- 
fested in an insignificant lesion or group of lesions, ephemeral 
in course, and limited to one portion of the body. 

The site of a syphilitic eruption may be determined appa- 
rently by the capriciousness of the disease, and yet result from 
local irritation of the skin of infected individuals. The accu- 
mulations on the napkin of the female invite the occurrence 
there of labial condylomata; the lips of the infant, after contact 
with the nipple of the mother, become the seat of rhagades and 
fissures; while the tongue of the tobacco-chewer and the fauces 
of the tobacco-smoker acknowledge similar sources of mischief. 

There are also some sites of preference for special lesions, as, 
for example, the squamous syphiloderm of the palms and soles, 
and the papules of the forehead, constituting the so-called 
"corona veneris." 

Amenability to Treatment. — Mercury possesses a singular 
influence upon the syphilodermata, which is promptly perceived 
when the drug is administered internally. This singularity 
rests upon the broad fact that the lesions of most other cutane- 
ous diseases not only refuse to acknowledge the benefit of such 
medication, but in many cases are aggravated by it. The im- 
portance of clearly recognizing the character of each cutaneous 
disorder submitted to treatment is thus clearly illustrated. 

Characters of certain Particular Lesions.— Certain fami- 
lies of lesions in syphilis, exhibit characteristic features. Thus 
some papular lesions are surrounded at the base by a peculiar 
fraying of the epidermis, in consequence of which they are 
encircled by a little fringe of scales resembling a collar. The 
scales of syphilis are usually not abundant, fine, dirty-whitish 
in color, or occasionally brownish. The crusts of syphilis 
are apt to be bulky, greenish-black in hue, and to surmount 
secreting ulcers of various depths. Such ulcers are generally 
circular, or exhibit in contour a tendency to assume the circular 
line, while the cicatrices by which they are succeeded have a 
similar configuration. The scars of syphilis are frequently 
smooth, delicate, very slightly depressed, unattached to subja- 
cent tissues, and pigmented. Lastly, from several of the secret- 
ing lesions of syphilis, especially those upon and about the ano- 
genital region, proceeds a discharge having an offensive odor 
and capable of communicating the disease to a sound individual 
by inoculation. 



442 DISEASES OF THE SKIN. 

Syphiloderma Maculosum. 

The cutaneous lesions of syphilis, limited to color changes in 
more or less circumscrihed areas of the skin, are exhibited in 
two distinct forms, due respectively to anomalies in blood and 
pigment distribution. 

(a.) The macular stphiloderm due to hyperemia is termed 
by several authors the erythematous syphilide, or syphilitic 
roseola. It is the earliest expression of cutaneous syphilis, and is 
more or less constant in occurrence, differing in this respect from 
several of the other syphilides. It is often unnoticed by the pa- 
tient, whose attention may be Hist called to it after its recognition 
by the skilled eye of another. It occurs in coffee-bean to filbert- 
sized maculae, roundish, ovalish, or of irregular contour, varying 
in color from a light rosy to a dull mulberry hue. In some 
cases these markings of the surface arc veiy indistinct, requiring 
for their recognition the closest scrutiny in a clear light, and 
occasionally even then leaving uncertainty in the mind of the 
expert. At times they constitute an. irregular "marbling" of 
the surface, of a kind which renders it difficult to define with 
the eye the individual lesions of which the eruption is composed, 
while the general visual effect of the exanthem is exceedingly 
distinct. They are not elevated above the general level of the 
integument, but may change in type, a papular lesion develop- 
ing later in the same site. 

Like all maculae of the skin due to vascular changes, they 
vary in color with the complexion of the individual, with the 
time which elapses after their first appearance, and with vascu- 
lar changes in the superficial plexus of bloodvessels. Thus the 
deeper shades are usually observed in thick and muddy-tinted 
skins; the more delicate, upon the breast, for example, of 
blonde women. The eruption usually appears between the 
sixth and eighth week after the appearance of the initial scle- 
rosis, and when untreated, develops for about one week more. 
It persists for a variable period of time, depending upon the 
severity of the constitutional disorder and the treatment to 
which the patient is subjected. During the early part of this 
time, the hue of the lesious is lighter, and they may be made to 
disappear under pressure; later, they are more deeply stained, 
and, exudation having occurred, the color of the spot does not 
disappear under the linger. When involution is in progress, 
there is slow disappearance of all symptoms of the eruption 
which fades gradually from view. The vascular changes in the 
capillaries occasioned by cold, heat, and rapid cardiac contrac- 
tions, all influence the eruption to a marked degree. A hot 
bath, a dance, a glass of spirits, a tit of excessive coughing, 
laughter, etc., may all bring the lesions into prominence. 

The eruption may be limited to the skin of the belly, extend- 



SYPHILODERMA. 443 

ihg also sparsely over the client, loins, ano-genital region, and 
thighs, the palms, soles, forearms, and legs; or, in exceptional 
eases, profusely cover the entire surface of the body, face, ears, 
dorsal surfaces of the hands and feet, and skin of the penis with 
the progenital region'. In the milder forms it is evidently sus- 
ceptible to external irritation of the skin, as it is common at 
the wrists where a starched cuff is worn, over the brow in the 
line covered by the hat-band, and particularly well-developed in 
males where the trowsers are "reinforced" (perineum and inner 
faces of the thighs). 

At times, as in the exanthematous fevers, the eruption is pre- 
ceded by a febrile state with marked amelioration of symptoms 
where the rash is fully developed; while again it is, throughout, 
accompanied by slight rise in the temperature, the patient hav- 
ing the so-called " bilious" appearance, muddy complexion, 
coated tongue, icteroid hue of 'conjunctivae, and offensive condi- 
tion of the breath. Wandering pains in the extremities, and 
especially beneath the sternum, are frequently experienced. The 
last mentioned is highly significant, and the whole is probably 
due to the effect upon the nervous system of the circulation of 
the recently intoxicated blood. These pains are not those pro- 
duced later in periosteal and other complications of the disease; 
and are the more significant as the eruption itself is productive 
of a scarcely appreciable subjective sensation. The superficial 
ganglia of the body are usually engorged at the same time; the 
fauces congested ; the hairs of the scalp slightly loosened in their 
follicles, and, in the latter region, in ' severe cases, papules and 
pustules may form. Inasmuch as the order of sequence of phe- 
nomena in syphilis is subject to a singular inversion, it occa- 
sionally happens that there is concomitance of later signs of the 
disease, such as iritis, affection of the nails and bones, or even, 
in places, pustular, papular, and squamous syphilodermata. 

Much less rare is the survival of the initial sclerosis to the 
date of this efflorescence. This is a point of considerable im- 
portance. The physician should never conclude the examination 
of a patient complaining of suspicious genital lesions, without 
carefully exploring the surface of the trunk; and also never 
pronounce upon an exanthem of this sort without minute inspec- 
tion and palpation of the part where an initial sclerosis may 
exist. In a diagnostic and therapeutic sense, the information 
thus gained may be precious, a^nd in a large proportion of all 
cases is of a kind quite hidden from the knowledge of the patient. 

Eelapses occur in certain cases with limitation of the disease 
to parts previously affected or unaffected. At the end of the 
first twelve-month, recrudescence of larger macula? in annular 
groups may occur. Exceptional forms are noted where darker 
puncta appear in the macular lesion, occasionally traversed by a 
hair. These are localizations of a more intensely hypersemie or 
exudative condition about the orifices of the ducts of the follicles. 



444 DISEASES OF THE SKIN. 

The diagnosis of this syphiloderm is readily established, in 
view of its essentially symptomatic character. From scarlatina, 

measles, and rdtheln, it differs in the indolence of the rash, the 
absence of decided elevation of temperature, and the order of its 
appearance in different portions of the body, as it rarely occurs 

first upon the face. Urticaria and the rashes induced by the 
ingestion of copaiba and other medicaments, are distinguished 
by the marked itching of the surface and their very general 
diffusion over the entire body rarely observed in the syphiloderm. 

Tinea versicolor, usually limited to the anterior surface of the 
trunk, is characterized by a lawn to chocolate tinted color, by 
the existence of the readily recognized vegetable parasite beneath 
the scales scraped from the surface, and by the furfuraceous des- 
quamation which the patient usually describes as most noticeable 
after a hot bath. It is, moreover, of much longer duration. 
Ringworm of the skin of the body is not symmetrical, and is 
also a parasitic disease. 

All these distinctions, however, are not to he compared for a 
moment in their diagnostic value, with the concomitant symp- 
toms of syphilis which are very generally present, such as aden- 
opathy, persistence of the initial sclerosis and evident involve- 
ment of other than cutaneous tissues. 

Such concomitant symptoms will he found occasionally with 
a non-syphilitic eruption due to ingesta swallowed for relief of 
the infectious disease. The most common of these is the iodide 
of potassium ; and the eruptions it produces are frequently found 
both commingled with the macular syphiloderm and occurring 
on the eve of the appearance of the latter. The existence of 
acneiform lesions upon the face, neck and posterior surface of 
the trunk, a vivid erythema of the forearms including the hands, 
and purpura-like maculations of the face, legs, and feet, should 
never mislead the physician as to the character of the disorder 
with which he is confronted. It is undeveloped syphilis with 
a dermatitis medicamentosa of the surface. Suspension of the 
iodide, which fortunately is not required in the immense major- 
ity of all such cases; the use of a properly selected mercurial, 
or even (and this is often wise), abstention from all medication, 
will be succeeded by disappearance of the cutaneous lesions, 
which may be followed later by a mild macular syphiloderm, 
altogether insignificant in comparison with the eruption artifi- 
cially induced. 

(b.) The second form of syphiloderm a maculosum is that due 
to anomalous distribution of pigment, descrihed by authors 
under the title of the pigmentary sypiiilide. The eruption, if 
such it may be called, is occasioned by the appearance upon the 
surface, of irregularly circular, usually poorly defined, dirty 
brown and chocolate tinted maeulse which, as they are entirely 
unconnected with vascular changes, do not disappear under 



SYPHILODERMA. 445 

pressure. The lesions occur as sparse and well isolated discolor- 
ations or, more commonly, as forming by a species of confluence 
an irregular rete or network, with relatively large interspaces 
characterized by an absence of such color. The eruption is most 
common upon the sides of the neck especially in blonde women, 
though it may more rarely involve the surface of the trunk 
and the extremities. It is also most frequent during the first 
year after infection, though it may develop later. 

According to Fox, of New York, the color changes observed 
in the skin are explained by the occurrence: first, of pigmentary 
deposit chiefly at the centre of the ordinary macular or papular 
syphiloderm; second, of peripheral absorption of such pigment 
with possible persistence at the centre of the lesion for a variable 
time; third, of total absorption of all pigment from the original 
lesion; and lastly, of peripheral hyperpigmentation of the spaces 
intermediate between the original maculse. 

The eruption is regarded by some observers as an epiphenom- 
enon of the syphilitic process, being not amenable to the treat- 
ment under which other macular syphilodermata speedily disap- 
pear. It is of rare occurrence ; and in the few cases where I 
have had the opportunity of studying its features, seemed to be 
an expression rather of general deterioration of the health of 
the skin than of specific disease. 

It is liable to be mistaken for that condition in which there is 
simply an accumulation upon a somewhat greasy skin, of secre- 
tions and dust, to be seen upon the integument long unwashed. 
Tinea versicolor has a more yellowish or fawn-colored tint, and 
is more abundantly developed upon the front of the chest than 
the neck. Neither chloasma, vitiligo, nor leucoderma are sym- 
metrically disposed, as is usually the pigmentary macular 
syphiloderm. 

Syphiloderma Papillosum. 

The type of all cutaneous lesions produced by syphilis, is to 
be recognized in the papule. Most of the others are either de- 
veloped from it, transformed to it, or by reversion or admix- 
ture, confess that the neoplasm of syphilis in the skin is essen- 
tially a more or less solid circumscribed cutaneous lesion, varying 
as to size and history. 

Papules, occurring in syphilis, may appear as the first cuta- 
neous evidence of infection, or may be developed from earlier 
macule. They may be small, acuminate, fiat, large, dissemi- 
nated, or in groups. 

Small Acuminate Papular Syphiloderm. — In this eruption 
the lesions are recognized as millet- to hemp-seed sized, circum- 
scribed, globular, acuminate, reddish, and salmon-reddish, firm 
elevations of the surface, or minute nodules upon the skin, gen- 
erally symmetrically developed, often over the entire body, 



446 DISEASES OF THE SKIN. 

closely set together, and occasionally grouped in crescentic 
figures. When viewed with care, a minute vesicle, pustule, or 
scale may be often detected at the conical apex of each lesion, 
which rarely develops to such an extent as to become a charac- 
teristic feature of the eruption. The color is at first, especially 
in blonde skins, a species of salmon and red, mixed ; later, the 
darker and browner shades appeal-. When generalized, the 
eruption is well developed, especially over the posterior i'aee of 
the body, the occipitocervical and scapular regions, the but- 
tocks and calves of the legs, though it is often distinct about 
the anus and genitalia. Like several other of the syphiloder- 
mata,its earlier are more symmetrical than its later manifesta- 
tions, whether these be tardy, or relapsing, or both. Involution 
occurs by resorption of the plastic exudate, minute and usually 
scanty, dirty-whitish, colored scales encircling the base of each 
lesion. When the eruption has proved especially persistent, 
marked pigmentation follows in the form of brownish-red 
blotches, the centre of each of which displays a cicatriform 
relic in the form of a punctum. 

The eruption is often first noticed about the forehead, nose, 
mouth, and neck, localities commonly subject to topical irrita- 
tion. Thus about the forehead in males, the papules will he 
frequently arranged along the baud pressed by the lining of the 
hat ; and the frequent fingering of the face, shaving, and irrita- 
tion by the edge of the collar of the shirt, may determine a 
more speedy efflorescence in the sites of contact. About the 
mouth, tobacco plays the role of an excitant; and about the 
nose, a localized seborrhcea may be added to the syphilitic lesions 
by similar irritants, in which case the lesions may be covered 
with slight, greasy crusts. The eruption is common during the 
first six months after infection, and is usually fully developed 
after a fortnight when no treatment has influenced its evolution. 
When the lesions are perforated by hail's, they suggestion super- 
ficial examination, a resemblance to lichen pilaris, and when ag- 
gregated in patches of distinct contour, they might be con- 
founded with psoriasis or squamous eczema. But in every case 
the physiognomy of the disease in general may well be trusted 
for the establishment of a diagnosis, having in mind the color, 
the absence of intense pruritus and serous exudation, the dis- 
position over the bod)' as a whole, or in portions widely sepa- 
rated, and the rarely failing concomitant evidence of syphilitic 
infection. 

Large Acuminate Papular Sypiiilodkrm. — Lesions of the 
character just described occasionally develop to an unusual de- 
gree, attaining the size of a coffee-bean in localities where the 
apex of each is free to push forward without coming into con- 
tact with adjacent planes of the integument. Thus about the 
dorsum of the body, the gluteal regions, the calves of the legs, 



S Y P H I L O D E K M A . 



447 



and the extensor surfaces of the forearms, they may be seen as 
fully developed, slightly scale-capped or scale-encircled and 
grouped papules, often commingled with pustules and superfi- 
cial ulcers, the polymorphic patch having a figure of eight or 
S-shaped outline. These are apt to be distinguished in patients 
under treatment, the influence of which has interfered with the 
full evolution of the disease. 

The Small Flat Papular Syphiloderm. — The lesions recog- 
nized under this title differ from those just described in that 
they are not acuminate, but distinctly flattened at the apex, 
this flattening being at times so pronounced that the lesion 
resembles a small button or plaque. The contour is roundish 

Fie. 45. 




(After Jullien.) 



or ovalish. They are frequently encountered on the face, espe- 
cially near the mucous outlets, over the anterior and posterior 
surfaces of the trunk, and on the flexor aspects of the extremi- 
ties. The palms of the hands are often affected. In color they 
exhibit the variation usual in individuals of different complex- 
ions, and in the same individual according to the condition of 
the circulation. Thus on the face, a scarcely distinguished pink 
will become a deep lurid reddish-brown from an attack of 
sneezing, a paroxysm of laughter or rage, and violent exercise. 
The seborrhoeic condition noted on the face in the acuminate 
lesions, is also occasionally seen about the plaques. The same is 
true of the scaling described above. The eruption is much less 



448 DISEASES OF THE SKIN. 

copious as a rule than with the other forms of syphilitic papules, 
due doubtless to the fact of its frequent occurrence in those sub- 
jected to some treatment. It differs from the lesion about to be 
described with respect to its size, being rarely larger than the 
smaller buttons employed as "shirt studs;" while the largest 
papule's of the same variety may attain the size of the largest 
overcoat button. The diagnosis is in general that already given. 

The Large Flat Papular Sypiiiloderm. — Here the resem- 
blance to a button is even more distinct, the lesions occurring 
with a well-detiued, firm, raised border, and a shallow depres- 
sion in the centre, though at times, especially in moist situations, 
the superficies of the plaques is a smooth, flat plane. They 
commonly begin as macular lesions and rapidly develop at the 
periphery, this development often corresponding to centric invo- 
lution by which the shallow depression described above, is re- 
duced to the level of the adjacent skin and the lesion trans- 
formed to a ring. In shape they are circular and ovalish ; and 
in size, vary from a finger-nail to the section of a pigeon's egg. 
They have the usual variation of color, and may scale at the 
edge, or over the flat top, or the depressed centre. In moist 
situations they frequently secrete a muco-purulent fluid which 
smears the papules and adjacent integument ; and in the vicinity 
of the anus or genitals exhales an offensive odor. It is espe- 
cially in such situations that they occasionally degenerate by 
fissure or circular ulceration. Condylomata lata are such lesions, 
flat and secreting papules of the region named, somewhat trans- 
formed by the influence of heat, moisture, and either friction or 
apposition of contiguous integumentary folds. 

The eruption may become generalized, or be limited to certain 
sites of preference, as the face, neck, flexor surfaces of the ex- 
tremities, and the ano-genital region. It is either an early, late, 
or intermediate symptom of syphilis, in my experience, occur- 
ring most abundantly in young and delicate skins, where the 
disease has been ignored, and therefore untreated; and most 
scantily in the thicker integument of middle life, where prompt 
resort has been had to appropriate medication. 



Syphilitic papules undergo a series of modifications, under 
the influence of various causes, which may be enumerated as 
follows : — ■ 

(a) There is considerable hyperplasia of the cutaneous ele- 
ments, (papillary layer of the corium, rete and bloodvessels) by 
which the papule becomes largely raised from the surface, so as 
to resemble a papilloma or wart, or the lesions characteristic of 
framboesia. In this way, rarely, a portion of or the entire surface 
of the body may be covered with light-red or violaceous red, 
non-ulcerative, vegetating growths. They secrete freely, and 
the discharge is liable to concrete into crusts, and to exhale an 



SYPHILODERMA. 



449 



offensive odor. De Amicis 1 has described a marked instance of 
this lesion occurring upon the scalp, under the title of the 
'• framboesioid condylomatous syphiloderra." A translation of 
his paper by myself, appeared in the Archives of Dermatology, for 
Oct. 1879, p. 39. 

(b) There is considerable hyperplasia of the elements, in con- 
sequence of which the lesion spreads laterally, while its elevation 
from the surface is prevented by contact with apposed surfaces. 
Thus is formed the broad, flat, moist papule, known as the vege- 
tating mucous patch, condyloma, plaque muqueuse, etc. The le- 
sions, when unaltered and fully developed, are of a decidedly 
whitish color, from the puriform mucus which covers them, and 
which, as with so many of the syphilodermata in moist situations, 
is liable to exhale an extremely offensive odor. When the se- 
cretion is removed, the lesions are seen to be pinkish, or light 
or dark red in color, and to be either firm or soft, scarcely raised, 
and indefinite in contour, or distinctly elevated and very well 

Fi«;. 46. 




Vegetatiug condylomata of the vulva. (After Ju 



defined. They are chiefly found in moist situations, where 
regions of the skin are apposed, as about the perineum, groins, 
axillae, mammse, nates, anus, genitals, and inner faces of the 
thighs. They may coalesce so as to form palm-sized patches, 
and frequently are associated with hyperidrosis, seborrhoea oleosa, 
and the dried products of secretions from the mucous outlets 
adjacent. 

(c) In consequence of changes in the superficial layers of the 
epidermis, the papules may become covered with scales, either 



29 



A.nnal. Clin, de Osped. Incurab. 



450 



DISEASES OF THE SKIN. 



at the base or apex, more commonly the latter, forming thus 
the papulosquamous Byphiloderm. The scales are of a dirty 
grayish hue, often desiccated, generally attached, rarely freely 
exfoliating. They are relatively few, occurring where the 
lesions are closely set together. The desquamation may be the 
most BUgge*tive feature of the patch. Beneath them, show dis- 
tinctively elevated brownish-red papules or merely slightly ele- 
vated, dull-red or purplish-red maculations. When the scales 
accumulate at the base of the papule, they tend to surround it 
with a circlet or collarette of exfoliated shreds of epidermis. 



In consequence of the thickness of the epidermis in the palrns 
and soles, the papular or papulosquamous syphiloderm of these 
regions, is presented under somewhat atypical forms. These are 
recognized as the palmar and plantar syphilides. The dense 
stratum corneum of the epidermis in these situations, is not 
•readily raised from its underlying tissue into papular forms. Its 
pathological manifestations in this disease are rather displayed 
in thickenings, separations, stainings, and frayings. 

Fig. 47. 





Palmar sypliiloderm. (After Keyes.) 



Here, therefore, are seen, dull-red maculations, covered through- 
out, or at the edge merely, by scales or epidermal shreds; minute, 
firm, corneous thickenings, few or niauj^, often without color in 
consequence of the depth of the vessels beneath the opaque horny 
layer; and distinctly elevated (not flattened) and circumscribed 
papules, of the usual livid-red color, coffee-bean to small-nut in 
size, often aggregated in patches having a tendency to assume 
the eircinate outline. These are covered with dirty-whitish, 
tenacious, half-loosened, epidermic flakes, which are quite charac- 
teristic. In yet other cases, usually in consequence of the mo- 
tions of the hand or foot or the exigencies of toil, irregularly 



SYPHILODERMA. 451 

angular losses of epidermis are visible, resembling the fracture 
of a pane of glass, which project, at the edges only, over deep 
fissures, broad exulcerations, or a ham-red, tender, and newly- 
formed epidermic stratum. 

The eruption is frequently seen in the centre of both palms 
and soles symmetrically, rarely upon the dorsum of the hands 
and feet, and then never typical, but always by extension from 
the former regions, also on the lateral surfaces of the hands, feet, 
lingers, and toes. It is a persistent, rebellious, and usually late 
cutaneous symptom of syphilis, occurring often six, eight, and 
more years after infection. Rarel} r it is seen within a few 
months after the existence of chancre, and is then usually mani- 
fested in its simpler forms. 



The papulosquamous syphiloderm bears in many instances a 
strong resemblance to the patches of psoriasis, but can usually 
be readily distinguished from the latter by a consideration of 
the following points: — 

The syphilide is as a rule not generally diffused; displays 
symmetry only when it involves the palms and soles ; is elevated 
at the border of the patch; and is displayed in the contour of 
the segment of a circle. Psoriasis is more widely diffused ; 
generally symmetrical ; not specially elevated at the border of 
the patches; and the latter are rather more completely than 
partially circular in outline. In the former, there is generally 
a history of infection, of other cutaneous or mucous symptoms 
of the disease, and in the married woman, of abortions, miscar- 
riages, or birth of diseased children. All this is wanting in 
psoriasis. In the latter, there is a decided predisposition to the 
development of the disease about the extensor surfaces of the 
joints and the posterior aspect of the trunk; the syphiloderm, 
though it may occupy these situations, can rarely be found thus 
displayed when the other surfaces are neglected. The scales in 
psoriasis are more lustrous; more freely produced and shed; and 
exist significantly at an earlier period of the exanthem. It may 
be safely said, that with only such exceptions as prove the rule, 
psoriasis upon the palms and soles does not exclusively occur. 
A scaling, palmar or plantar disease of the skin in childhood, 
is more apt to be psoriasic, though both diseases are seen in the 
early periods of puberty. 

Eczema is yet more readily recognized by its severe itching, 
its history of discharge and moisture, and its characteristic 
crusts. Ancient patches of squamous eczema are often very in- 
determinate in outline, do not ulcerate, and exhibit the scales 
on the surface of a much more deeply infiltrated area. Eczema 
of the palms and soles, when chronic, usually involves the dor- 
sum of the hands and feet, whence it has extended to the former 
situations. When this is not the case, the eczematous iufiltra- 



4.")2 DISEASES OF THE SKIN. 

tion, if of long duration, will, in the vast majority of all cases, 
be found to involve uniformly and evenly the entire palm or 
Bole, including the palmar or plantar faces of the digits. Eczema 

is, finally, much more frequently encountered either solely upon 
the right hand in right-handed patients, or to a greater extent 
in that organ by reason of its preference in the performance of 
function. This is rare in syphilis. 

Syphiloderma Vesiculosum. 

The vesicular are either the rarest of all cutaneous symptoms 
of syphilis, or do not actually exist. Certain French authors 
describe pin-head to pea-sized, conical, globoid or umbilicated, 
isolated or grouped, and crusting elevations of the epidermis, 
with lucid or cloudy contents, seated upon the face and genita- 
lia. The eruption is described as an early syphiloderm, often 
exhibiting a halo of characteristic tint, the resulting crusts 
being granular and somewhat lighter in color than those which 
are commonly seen in the disease. Both small and large vesicles 
have been thus assigned to the disease. 

But the larger number of such lesions are, without question, 
cither immature pustules, eczematous lesions in syphilitic sub- 
jects, or pure accidents of the syphilitic process. With regard 
to the first, it may be said that the pustular syphiloderm not 
rarely begins as a vesicular lesion; with regard to the second, 
that coincidences of so common a disease as syphilis with other 
cutaneous disorders, is a matter of frequent observation; and 
with regard to the third, bearing in mind the large quantity 
of the iodide of potassium swallowed for the relief of the 
disease, and its capability of exciting a vesicular eruption, it can 
be reasonably concluded that some, at least, of the cases of so- 
called vesicular syphilis have been imperfectly studied. 

Syphiloderma Pustulosum. 

Pustular lesions in syphilis present a wide range of differ- 
ences. They vary in size from a pin-head to a linger nail; may 
he acuminate, fiat, hemispherical, or irregular in shape; may be 
few or very numerous; distinctly localized or generally dis- 
persed; grouped or disseminated; and may occur from the first 
as minute vesico-pustules, or as pustular transformations of vari- 
ously sized papules. They may be surrounded by inflammatory 
areolae, or spring from an unaltered integument, or be sub-epi- 
dermic in situation, and scarcely project from the surface. They 
may be seated upon superficial or deep, sharply-cut, secretory 
ulcers, and are usually followed by crusts differing in bulk and 
consistency, forming thus the pustulo-crustaceous syphilide. 
According to the depth of the ulceration at the base are they 
followed by cicatrices. Pigmentation is a frequent result. The 
crusts which form by the desiccation of their contents, are usu- 



SYPHILODEHMA. 453 

ally reddish-brown to greenish-black in hue, occur in strata or 
laminae by accretions from beneath, and even when superimposed 
upon a moist and secreting ulcer, are quite adherent at the edges. 
They may occur early or late in the disease, and at either epoch 
constitute trifling or grave cutaneous lesions. They have a 
marked predisposition for involvement of the sebaceous and 
pilary follicles, and are frequently disposed about the mucous 
outlets of the body. 

Small Acuminate Pustular Syphiloderm. — This exanthem 
is usually largely diffused over an extensive surface, and pro- 
bably represents, as Jullien has suggested, a transformation 
from papular lesions due to either a pyogenic tendency of the 
infected subject, or to uncleanliness and external irritation of 
the skin. It is certainly rare in patients of the better class 
who are seen in the private clientele of the physician. The 
pustules are generally recognized about the pilo-sebaceous ori- 
fices, and upon minute papular lesions, which, as undisguised 
elements of the eruption, may be interspersed among the latter. 
They are acuminate, and contain but a droplet of cloudy serum 
or pus, whose desiccation furnishes a thin yellowish or reddish- 
brown crust. The fall of the latter exposes the grayish epider- 
mal fringe of the base occasionally seen in papules of similar 
size. 

The lesions may be discrete, confluent, disseminated, or in 
groups affecting the curve of a circle. The extremities and 
trunk are chiefly involved, though the disease may be well-nigh 
universal. Under the influence of treatment, minute, puncti- 
form,and pigmented cicatricial atrophic depressions form, which 
are not persistent. The eruption may be an early or late secon- 
dary symptom, but is usually first seen within a few months 
after infection. Relapses occur when treatment has been irregu- 
larly pursued. Their concomitants are those symptoms of syphi- 
lis proper to the period in which they appear. 

Large Acuminate Pustular Syphiloderm. — The lesions are 
here usually coffee-bean sized pustules, which may spring from 
macular or smaller pustular lesions, very rarely from an indu- 
rated or papular base. They have a thin roof-wall, occurring 
by preference where the epidermis is delicate, and are often sur- 
rounded by a halo. They are usually acuminate, but may, after 
full evolution, slightly flatten at the apex in consequence of 
partial collapse. The crusts are bulkier and darker in color 
than those of the lesions just described; their bases are superfi- 
cially ulcerated. They occur slowly or with rapidity, in dis- 
seminated or grouped forms, usually at an early period of the 
disease, though commonly after the appearance of some syphi- 
lide of another type. 



454 DISEASES OF THE SKIX. 

Small Flat Pustulab Syphiloderm. — This is a relatively fre- 
quent manifestation of By phi lis, occurring upon the face, scalp, 

trunk, and the flexor surfaces of the extremities. It exhibits a 
decided tendency to characteristic and circular grouping about 
the mucous outlets of the body. Such groups are composed of 
small, flat pustules, originating as reddish, macular lesions 
which tend to dry in flattish, irregular, adherent crusts; and 
the latter either surpass the limits of the diseased surface be- 
neath, or are conspicuous upon a dull brownish-red area of in- 
flamed, and even at times ulcerated, aspect. Often the pustules 
are so closely set as to become confluent, and in such case a single 
convex crust, like a carapace, will often completely cover the 
involved area. Frequent sites of the exanthem are the regions 
about the nose and the lips; as also the chin, heard, and the 
anterior faces of the elbow and wrist joints. 

The eruption is of the pustulo crustaceous type and may be 
evolved from either papular or macular lesions. In this coun- 
try, it is rarely long untreated; and when in full evolution is, 
therefore, not often presented for observation. It is usually 
amenable to judicious treatment, and when followed by severe 
ulceration, destroying one ala of the nose or a part of the lip, 
the patient has usually suffered from either cachexia or neglect. 
Tn these same cases, less severe phenomena are presented in the 
superficial serpiginous syphilide, the lesions extending in circi- 
nate or annular gyrations about a sound or previously involved 
and healed centre. Thus a circlet of crusts with underspreading, 
superficial ulceration, perhaps alternating with pustules of vari- 
ous ages and reniform cicatrices, will surround the elbow or 
traverse the scalp. The resemblance to pustular eczema is at 
times suggestive; but the ulceration and outline will aid in their 
discrimination. The lesions are usually late among the earlier 
symptoms of the disease; but may be delayed for six months 
after infection. They indicate, as a rule, either severity of the 
disease, or, much more commonly, constitutional impairment. 

Large Flat Pustular Syphiloderm. — The lesions here are, 
naturally, fully developed forms of those described above. Like 
the latter, they originate as usually numerous, maculo-papular 
symptoms, which gradually deepen into pea-sized and even 
larger flat pustules, whose further history is one of enlarging, 
blood-mixed, reddish- and greenish brown, also flattish cruots 
with underspreading pus-bathed ulceration, of varying extent. 
The superficial variety of this syphiloderm is distinguished from 
the deep, chiefly by the extent of its ulcer, the size of its super- 
imposed crust, and the slighter dull-red areola which encircles it. 

The deep variety, like the superficial, may be limited to the 
scalp, face, neck, and flexor aspects of the extremities; or it may 
be much more widely diffused. I have seen the entire surface 
of the body covered with discrete lesions of this type in cases of 



SYPHILODERMA. 455 

unusual neglect or profound cachexia. It is usually of late 
occurrence, but in the so called '-'galloping syphilis" of the 
French, it may be precocious in development. The lesions are 
at the onset nodules or tubercles, which become transformed 
into pus, and which have a deep infiltrated base with a dark 
brown halo. Incrustation follows, with the formation of a 
conical, roundish or ovalisb, blackish-brown crust, beneath which 
lies a clean-cut ulcer, its sharp edges usually exactly roofed by 
the incrustation. The crust thickens by concretions from the 
foul and purulent ulcer beneath; and spreads at the periphery 
while it thickens in the centre. In this way the stratified 
crust comes to resemble an oyster shell, the condition described 
by some authors as rupia, a term once employed as the name of 
a disease. The ulcer which is exposed after removal of the crust 
is of characteristic syphilitic type, in its deep base, foul floor, 
cut edges, and sanguineo-purulent secretion, attaining at times 
a diameter of several inches and having a circular, reniform, or 
horse-shoe shaped contour. The degree of destruction it may 
occasion is proportioned to the constitutional vigor of the sub- 
ject and the treatment pursued. It is usually a grave but may 
be a malignant exanthem, though under favorable circumstances 
it is easily managed. It may be an early, though usually a late 
symptom of the disease. The pigmented scars left are charac- 
teristic and indelible. 

Syphiloderma Bullosum. 

Bullae in acquired syphilis are late and relatively rare lesions. 
They are pea- to large nut-sized elevations of the epidermis, 
filled at first with a cloudy serum, which is soon transformed 
into pus and often mingled with blood. They have usually a 
characteristic halo about the periphery; are roundish or ovalish 
in contour; are usually discrete; rarely disseminated; and, after 
development, produce characteristic crusts with underlying 
ulcers, identical in features with the rupioid sequelae of large 
syphilitic pustules. The eruption is localized by preference 
upon the extremities, more particularly the lower extremities; 
and is indolent in its course. It is always significant of a 
cachectic condition in the subject of the disease. Its more fre- 
quent occurrence in congenital syphilis will be described later. 
It is to be distinguished from pemphigus vulgaris by its charac- 
teristic crusts and ulcers, considered in connection witli the his- 
tory and associated symptoms of lues. 

Syphiloderma Tuberculosum. 

In this eruption, the lesions are usually multiple, flat, round- 
ish, circumscribed, firm, light to dull crimson-red excoriations, 
beginning commonly as maculse of a lurid hue. They vary in 
size from a coffee-bean to small nut, and involve the entire 



456 DISEASES OF THE SKIN. 

thickness of the skin, often also of the subcutaneous tissue. 
Their surface is smooth, glazed, or desquamating; and their 
evolution peculiar in this, that they rarely exhibit apicial pus- 
tulation or ulcerative degeneration. 

The eruption is, with few exceptions, usually limited to one 
or more regions of the body, such as the forehead, the chin, the 

Fi.sr. 48. 




"%>, 



Ulcerative tubercular syphiloderm. (After Keyes.) 

nucha, the buttocks, and the outer surface of the thighs. It is 
less often disseminated than grouped. Occasionally but a single 
tubercular lesion may he displayed upon the surface of the body, 
the recognition of whose character usually demands some skill 
on the part of the diagnostician. When occurring in groups, 
the typical circinate appearance of the syphilodermata in general 
may be wanting, the patches having an irregular boundary ; but 
at times the circular, reniform, or horse-shoe shaped outline is 
quite distinct, with an inclosed area of integument, unaltered 
or the seat of atrophic changes. At other times the lesions 
assume a serpiginous character and distribution, a condition to 
which the term 

Serpiginous Tubercular Syphiloderm 

has been applied. Bumstead and Taylor, however (wisely it 
seems to me), prefer to reserve that title for the description of 
the serpiginous syphiloderm of ulcerative type. 

In exceptional cases, the lesions thus described are marked by 
secondary changes. They may become covered on the surface 
with a thin yellowish crust; may lose their firmness and become 



SYPHILODERMA. 457 

softish and rather more lurid-red in hue from colloid, or even 
rarely suppurative, degeneration ; may vegetate luxuriantly 
and become the seat, especially on the scalp, of warty growths, 
smeared with a semi-purulent secretion of disgusting odor (syph- 
ilis papillomatosa, syphiloderma framhoesioides) ; or may finally 
ulcerate, the superimposed crust thickening in bulk, deepening 
into blackish and greenish shades, and covering typical syphilitic 
exulcerations, with characteristic edges, floor, base and secretion. 
The degeneration in the latter case may be rapid, and the de- 
struction extensive. This is, however, of rare occurrence. 

The course of the eruption is indolent, months usually elapsing 
before its full evolution is accomplished. In untreated cases 
there is unquestionably produced a generalized and symmetrical 
syphiloderm. It is rare, however, even in hospital and dispen- 
sary cases, to observe such generalized development ; the more 
superficial, generalized and symmetrical the lesions, the briefer, 
as a rule, is the interval between such an eruption and the date 
of infection. The later the lesions, the more apt are they to be 
asymmetrical, localized, and profound in their involvement ot 
the deep tissues. This syphiloderm rarely appears in the second, 
more often in the third or fourth, still more rarely in the fifth, 
tenth, or fifteenth year of the disease. 

Resolution occurs by resorption leaving in the site of the 
tubercles, according to their age, size, and contents, livid and 
pigmented maculations, or peculiar, pigmented, atrophic, cica- 
triform areas. Scars following the ulcerative lesions are typical 
in color, shape, and career, the pigmentation of both cicatrix 
and areola blanching from centre to periphery, and leaving a 
delicate, dull-whitish, glazed or slightly desquamating mem- 
branous new growth, ancient relics of this process resembling in 
appearance thin, coin- and larger-sized, circular sheets of mica. 

The diagnosis is between lupus vulgaris, lepra, epithelioma, 
and psoriasis. In lupus, the age of the subject, the character 
of any scars left upon the surface, the chronicity of the disease, 
and the absence of a history of polymorphism, will usually point 
to the nature of the disease. The tubercles of lepra are very 
much more indolent than those of syphilis, and have a charac- 
teristic oiled or varnished look, never the livid or dull crimson 
color of those last-named. Set upon the forehead, the tubercles 
of syphilis, nearer the line of the hairs, never give the leonine 
aspect of those at the lower border of the forehead and over the 
eyebrows of the leper. In epithelioma, the age of the subject 
and the history of the disease are always significant. In the 
early stage of epithelioma, the patient is often in a condition of 
excellent general health, while the imprint of cachexia is dis- 
tinct in tubercular syphilis of the skin. In the later stages of 
epithelioma, the ulcer with everted edges and eroded, hsemor- 
rhagic floor, "varnished" by its translucent secretion, is totally 
different from the "punched out," syphilitic ulcer with its puri- 



45S 



DISEASES OF THE S K I X . 



form Becretion and discolored crusts. The deep infiltration of 
even the desquamating tubercular syphiloderm will distinguish 
it from the circular patches of psoriasis. 



Syphiloderma Gummatosum. 

The gumma is a lesion peculiar to syphilis; no other disease 
exhibiting an exactly similar feature. It is usually a late or 

so-called tertiary manifestation 
of the disease ; and is com- 
monly observed in the form of 
one or relatively few, subcuta- 
neous, strictly circumscribed, 
firm, well rounded, painless and 
indolent tumors or nodules 
which, when first observed, are 
scarcely larger than a pea. They 
are then covered by an unal- 
tered integument and are quite 
movable. 

Very slowly they may, when 
untreated, increase in size till 
they have the dimensions of a 
marble, an egg, or even bodies 
of a considerably larger size. 
Sooner or later, when not re- 
solved by treatment, they usu- 
ally become attached and the 
overlying skin becomes in- 
volved, showing by its livid, 
reddish or purplish hue and its. 
by peraamicareola, that it threat- 
ens to yield. Finally, at one or 
several points, the skin is so 
thinned as to be incapable of further resistance, and a thick 
sanious secretion is exuded, whose gummy character has given 
the lesion its name. When the inflammation has been active, 
its secretion may be wholly or partly purulent, and in that case 
be furnished either, by the contents of the tumor, or the periph- 
eral tissue which participates in the process. Ulcers always 
result, occasionally fistulous in type, roundish, or ovalish in eon- 
tour; with edges clean cut, and floor purulent and extending to 
the subcutaneous tissue, tendons, aponeuroses, cartilage or bone. 
Thin and yielding bands or bridges of undermined skin often 
extend between several such solutions of continuity, and usually 
melt down in the presence of the destructive process. When 
repair is progressing, which is decidedly the rule as regards the 
ultimate result, granulations spring from the floor, the edges 
contract, and the gummatous eventually exhibits the appearance 




(After 



SYPITILOPERMA. 459 

of a simple ulcer, save in the thinned, purplish, pigmented 
appearance of the outlying integument. The scars are typical, 
bleaching from the centre, and may be attached to periosteum 
or bone, though this is exceedingly rare. Considering the depth 
of the process, the gumma of the skin is certainly as a rule 
succeeded by less evidence of destruction than is threatened at 
the height of the process. About the neck, the cicatrices may 
be linear in shape and slightly puckered. Upon the lower ex- 
tremities and trunk, they are usuallj* circular or oval. 

But one gumma may appear upon the person of a single indi- 
vidual and, when this is the case, it will usually be found upon 
the leg. Half a dozen or more may at other times coexist. In 
one instance, I counted nearly one hundred upon the person of a 
gentleman who was the father of two syphilitic children, and 
who at the time had also symptoms of visceral syphilis. This 
number is greatly in excess of any previously observed by me 
in a single case. Gummata may develop upon any part of the 
body, and when situated over the trunk of a nerve become the 
seat of severe neuralgic pain. They are particularly amenable 
to treatment; and may undergo resorption, leaving little or no 
trace of their former existence. 

Gummata. are to be distinguished from fibrous, carcinomatous 
and lipomatous tumors, as also from indurated and enlarged 
lymphatic ganglia. As they occur in very marked preponder- 
ance below the level of the knees, and are for the most part 
single or relatively few in such situation, they can by their 
position alone be frequently differentiated from each of the new 
growths mentioned, no one of which occurs by preference upon 
the lower extremities. As they are, moreover, relatively late 
lesions of syphilis, a history of pre-existing symptoms of that 
disease can usually be obtained. 

Syphiloderma Infantile, Acquisitum et Hsereditarium. 

Syphilis may be acquired by the infant and child at any period 
after birth, as for example, by immediate contagion from the 
nipple of the nurse, or mediately, as by the use of utensils 
smeared with a secretion capable of transmitting the disease. 
Such acquired infantile disease displays for the most part the 
symptoms observed in adult years, except that the delicate and 
tender skin at this early period of life, is apt to exhibit the 
moist and secreting lesions of syphilis. The mucous patch, the 
pustule and the condyloma, are here more common than the 
papulosquamous symptoms of the adult. Some influence is 
also exerted upon the disease by the dress, habits of life, 
and mode of obtaining nutriment, which are conditioned upon 
the helplessness of the young child. In this w T ay the soiled 
napkin over the ano-genital region, the warm covering and free 
diaphoresis from the general surface of the skin, and the fre- 



460 DISEASES OF THE SKIN. 

quent contacts of the lips with the nipple, suffice to determine 
in Bpecial regions, [>artiuular local expressions of the constitu- 
tional vice. It is much less grave in character and portent, than 
the inherited form of the disease. 

Hereditary syphilis may occur in infancy or early adult years, 
and is always strictly transmitted by inheritance from one or 
both parents. The consideration of the disease being in these 
pages limited to its cutaneous manifestations, it is first to be 
noted that the infected foetus may he prematurely expelled with 
cutaneous symptoms displayed upon its surface. This generally 
argues in favor, either of intense syphilis in one or both pro- 
genitors, or, more commonly, of relatively recent infection of 
the latter. Under these circumstances, there are usually evi- 
dences of the death of the foetus for some days prior to its ex- 
pulsion, the skin being macerated and the epidermis raised from 
the corium in few or many bullous lesions, beneath which the 
derma exhibits a livid reddish or purplish hue. 

When the infant is born with a clean skin, it may be shriv- 
elled and emaciated, or fat and presenting the appearance of 
sound health. Soon after, however, cutaneous manifestations 
appear, usually not before the conclusion of the Hist month, 
more commonly during the second, very rarely after the third 
and fourth. The earlier the date of such explosion, the more 
intense as a rule is the evidence of the disorder. The first symp- 
toms displayed are significant of visceral involvement, and are, 
in brief, those of marasmus. Emaciation progresses rapidly ; 
the skin seems stretched unnaturally over the facial bones; the 
expression is that of physical distress; the cry becomes a fretful 
moan ; the integument loses entirely the rosy hue of the healthy 
infant, and acquires instead a sallow or muddy tint; and very 
peculiar wrinkles or puckered lines radiate from the angles of 
the lips. Few observers have failed to notice the resemblance 
which then exists between the faces of these emaciated little 
creatures and those of the aged of both sexes. 

In all this, however, there is absolutely nothing character- 
istic of syphilis, as distinguished from other wasting diseases of 
infancy. Chronic tubercular meningitis and the gastro-intestinal 
disorders of infancy in their extreme expression, furnish a pre- 
cisely similar picture. This is natural enough, since all depend 
alike upon a similar cause, failure of proper performance of func- 
tion on the part of the viscera in consequence of pathological 
alterations. 

The coryza of the syphilitic infant is, however, soon declared, 
and speedily gives a clue to the nature of the morbid process. 
The discharge from the nares, at first serous, later purulent, 
desiccates sufficiently to obstruct the nasal passages, or, in con- 
sequence of the tumid condition of the membrane enveloping 
the latter, is prevented from escaping. Often it is furnished by 
mucous patches forming on the Schneiderian membrane. At 



SYPHILODERMA. 461 

times, its crusts form so as to accumulate externally about the 
nasal orifices, and then are seen to he similar to those which are 
apt to form also at the angles of the mouth. In this way the 
characteristic "snuffles" of the syphilitic infant is induced, in 
consequence of which it is obliged when nursing to release the 
nipple from its mouth, in order to respire, an act usually accom- 
panied by a hoarse cry. The breathing of such an infant, even 
when asleep, or awake and undisturbed, is always sufficient to 
arouse a suspicion as to the nature of the disease from which it 
is suffering. The mouth, larynx, vulva, and anus are often the 
seat of similar lesions, whose development into an obstructive 
tumefaction secreting more or loss profusely, or into moist con- 
dylomata, will depend largely upon the seat and surroundings 
of the lesion. 

The cutaneous symptoms of the disorder, presented usually 
at or about this time, are macular, papular, pustular, bullous, 
or furuncular, two or more of them being at times commingled, 
attesting thus the identity of the disease with the polymorphic 
acquired forms of maturer years. Macula? are early to appear 
upon the trunk, face, and extremities, usually of a livid reddish 
hue, commingled with papules, and indeed often occurring as 
the first manifestation of the latter. They are irregular as to 
shape, and though occasionally pinkish, discrete, cireinate, and 
coffee-bean sized, often constitute a diffuse, coppery-red, or vio- 
laceous, glazed, or moist and secreting surface, affecting an en- 
tire region as the neck, the trunk, or thighs and genitalia. Deep 
excoriations and even fissures occasionally form in these exten- 
sive patches, and the secretions may incrust them irregularly, 
the general aspect of the patch somewhat suggesting an ecze- 
matous condition, yet remarkably differing from the latter in 
color. 

In hereditary as in acquired syphilis, the type of all the erup- 
tive symptoms is to be sought in the papules which may spring 
from the macula? described above, and develop into pustules, 
bulla?, or condylomata; and, in the former case, dull red or vio- 
laceous papules of lenticular size, occur either in asymmetrical 
or symmetrical arrangement, discrete or agglomerated in patches 
of infiltration. They may, upon the buttocks especially, scale 
at the apex; or, particularly upon the palms and soles, consti- 
tute by fusion a thickened desquamating epidermal patch ; or, 
commonly about the ano-genital regiou, the interdigital spaces, 
the axilla? and face, become moist, and secrete a puriform mucus. 
By vegetation or hypertrophy, they develop into fiat or fissured 
condylomata, smeared with an offensive, yellowish or yellowish- 
w r hite discharge, and vary in size from a coin to a lesion an inch 
or more in diameter, with corresponding variation in the degree 
of their elevation from the surface. The latter may be few or 
very numerous. Sometimes a child will appear to be well nigh 
covered with large, moist, secreting papules. I have seen au 



462 DISEASES OF THE SKIN. 

infant with snuffles and macula of t he trunk, having but a 
single condyloma of the anal region. Again, the papule-condy- 
loma may ulcerate deeply and crust. It should he remembered, 
in Btudying these symptoms from verbal description, that they 
are those of a cachectic infant affected with a grave disease. 
Death often interrupts the sequence of the manifestations here 
described. This event is usually preceded by the signs of ap- 
parent amelioration, shrinkage of hypertrophic growths, and 
deeolorization of hyperaemic lesions and patches. 'Of the other 
cutaneous symptoms of hereditary syphilis, vesicles are the 
rarest, the smaller being occasionally seen, having a conical 
apex, with serous contents, closely set together about the lips. 
and springing from a violaceous infiltrated patch. The resulting 
crusts never have the reddish-yellow tint of those observed in 
eczema, nor. after rupture, are they followed by serous oozing 
from a wounded epidermis. The larger lesions of this sort are 
usually transformations of papules which rapidly assume a pus- 
tular phase. 

Pustular eruptions, in this form of syphilis, may be discrete 
or confluent, localized or generalized. They are particularly 
apt to occur in groups about the mucous outlets, with maculo- 
papular lesions developed elsewhere, and may result in ulcera- 
tion, often after development into bullae with pustular or sanious 
contents. The resulting crusts are bulky and dark colored, and, 
especially upon the face, disfiguring. The subjective sensations 
are probably insignificant, as the child does not attempt to tear 
the surface, as in pustular eczema. The cachectic condition of 
the little patient, when these lesions are large and numerous, is 
usually pronounced. They may be seen in typical development 
by the side of the nail, occasionally involving the matrix, and 
productive, in this situation, of considerable swelling of the 
digit, with an ulcerative sequel, which commonly results in dis- 
tortion, and ultimate loss, of the nail-substance. Onychia, how- 
ever, may result from perverted nutrition of the part, with 
increase in its friability, loss of lustre, assumption of a dirty 
grayish hue, and phalangeal oedema. These changes are analo- 
gous to those resulting in loss of the hair where the follicles 
have been imperfectly nourished. 

The furuncles which form in other cases are exaggerated 
manifestations of the same pyogenic tendency in the skin of the 
infant, a complication common to syphilitic and other cachectic 
conditions in young children. They may be few or numerous, 
and are chiefly characterized by their indolence, the absence of 
laudable pus in their contents, the ulcerative condition left after 
their evacuation, and the bluish or purplish condition of the 
integument which surrounds their edges. 

Bullae in hereditary syphilis are early or late manifestations 
of the disease, and may be represented by a single lesion on the 
palm or soles (the site of their predilection), or constitute a 



SYPH1L0DERMA. 463 

symmetrical generalized efflorescence. They should be regarded 
as evidences of a grave form of the disease, being often the pre- 
cursors of a fatal issue, as indicating a feeble resistance on the 
part of the epidermis to the fluid exudate furnished from the 
corium beneath. In severe cases, the bullpeare illy developed, 
and the integument will be seen to be marked here and there 
by. small coin-sized and larger disks or plaques of macerated 
epidermis, separated from the derma by a thin film of serous, 
sanious, or purulent fluid, in quantity insufficient to raise the 
roof above the general level of the integument. When fully de- 
veloped, they may be conical, rounded, flat, or quite flaccid, 
and surrounded by an infiltrated border of dark reddish or vio- 
laceous hue. Their color varies with the color of their contents. 
Their subsequent career is concluded by shallow or deep ulcera- 
tion, the base secreting a sanious discharge. Crusts may form 
if the patient survive. A fatal termination of "the disease is 
usually announced by their flattening or collapse. They may 
be commingled with pustules and maculo-papules, condylomata, 
mucous patches of the anus, mouth, and nares, but are some- 
what different from the other lesions described in this, that they 
may constitute a uniform efflorescence, no other cutaneous symp- 
toms being manifested. This is explained by the fact to which 
attention has been directed, that they represent the state of 
feeblest resistance in the epidermis, the fluid exudate of exceed- 
ingly low grade mechanically separating the rete from the tis- 
sues beneath. 

Tubercles and subcutaneous gummata may occur in hereditary 
syphilis, but are usually late manifestations of the disease, one 
or more years elapsing before their appearance. Tlieir behavior 
is scarcely different from that of those observed in the acquired 
forms, although the destruction wrought by their degeneration 
in very late manifestations, may be of the most intractable type. 
Usually there is a preceding history of parental or inherited 
disease, and coincident symptoms or sequehe of such, in the 
altered teeth, described by Hutchinson, of London, in an ancient 
keratitis, or in a hopeless form of surdity. 

Mucous patches are very constant symptoms of the disease, 
and represent papules of the mucous membrane, which differ 
from those seen in the skin only because they are moistened, 
macerated, and flattened by juxtaposition of neighboring tissues. 
They are surrounded usually by a lurid halo, and may have the 
pearly whiteness always seen when the epidermis of mucous 
membranes is detached wholly or partly from the corium ; or 
may lose this protecting disk in shreds or patches, and show 
beneath an engorged, or ulcerated and secreting tissue. They 
may be isolated or broadly confluent; and ovalish, circular, and 
decidedly linear in shape; the last named appearance being 
characteristic of those existing at the angles of the mouth. 

They are to be recognized as distinct from both the parasitic 



4G4 DISEASES OF THE SKIN. 

and non-parasitic forma of simple stomatitis or thrush, the 
former being due to the presence of the oidium albicans. In 
both of the non-syphilitic disorders, the month of the child will 
he seen to be very generally, uniformly, and symmetrically in- 
volved, the circumscribed patches being distinctly discrete and 
resembling in color, soft whitish or yellowish floccuii of curdled 
milk. The diagnosis is always greatly aided l>y noticing the 
well-nigh constant occurrence of patches just at the angles of 
tin' syphilitic month, which latter lias also the seamed and 
puckered appearance described above. Snuffles, syphilodermata, 
and marked cachexia, when established, will leave little doubt 
as to the nature of the malady. 

The future of the infant affected with hereditary syphilis is 
not always as dark as might be gathered from what has pre- 
eeded. In this, as in the acquired form of the disease, benign- 
ancy may be a conspicuous feature of the entire process. The 
evolution of the disease may be tardy; its symptoms few and 
unimportant; its amenability to judicious treatment, speedily 
demonstrated. Still, the fact remains, that the disease when 
inherited is far graver than when acquired, the victim entering 
the world with its viscera and bones liable to profound patho- 
logical alteiations. 

Etiology. — Syphilis, in the course of which appear the syphi- 
lodermata, is produced invariably either by infection, accidental 
or intentional, or by the obscure influences of heredity. The 
methods of transmission may be immediate as in sexual con- 
gress, kissing, and nursing at the nipple, by which the child 
may infect the nurse with the secretion of the mucous patches 
in its mouth, or may, instead, receive the disease from the exco- 
riations on the breast of the latter. Or the disorder may result 
from the medium of utensils charged with an infectious secre- 
tion, such as the needles of the tatooer wet with saliva commin- 
gled with diseased mucus, or the lancet of the vaccinator covered 
with an intoxicated blood. Generally it may be said that all 
the discharging and moist syphilodermata are sources of danger 
to a sound individual, both in the acquired and inherited forms 
of the disease. By these and other similar methods, persons of 
both sexes and all ages may become infected. 

However begotten, the syphilodermata are yet not excluded 
from subjection to the long list of external irritants which may 
in turn annoy the skin. The influence of a hot bath, or the 
excitement and perspiration of the dance, will often invite to 
the surface a macular syphilide which might otherwise be less 
fully developed; and friction, as by the hat-band over the fore- 
head, the cuff at the wrist, and the shoe over the foot, demon- 
strates its influence by daily examples of determination of the 
morbid process to special localities. The same may be said of 
tilth, as the feces on the napkin of the infant which frequently 



SYPHILO DERMA. 465 

provoke in this region the vegetation of condylomata. It is a 
mistake to suppose that syphilis and syphilis only is responsible 
for the exanthemata of that disease in all shades, grades, and 
situations. Soap and water are as efficient in preserving the 
skin of the syphilitic as of the sound; and the infected tobacco- 
chewer pays a price for his nauseous habit. Poverty, misery, 
and wilful neglect or ignorance of the laws of hygiene, are re- 
sponsible for a long and lengthened list of the complications 
of the disease. 

Pathology. — The pathological anatomy of syphilis and the 
syphilodermata, has been carefully studied by a large number 
of observers, including Virchow, Wagner, Coruil and Ranvier, 
Neumann, Auspitz, and Biesiadecki. It must be admitted that 
the result, even though it present a fair picture of the pathologi- 
cal appearances exhibited by the several lesions subjected to ex- 
amination, is yet far from furnishing an explanation of the 
nature and peculiarly capricious career of the disease. With- 
out stopping to consider, much less discuss, the numerous con- 
flicting theories respecting the nature of syphilis, which the 
investigations of the eminent authors named have not yet suc- 
ceeded in either disproving or establishing, it can be merely 
asserted to-day that the solution of this important question has 
not yet been reached. Under the microscope, it can be clearly 
determined merely, that the recognized processes of hypersemia, 
exudation, hypertrophy, new growth, and degeneration (caseous, 
fatty, amyloid, atropine, and necrotic) occur in syphilis as in 
some other disorders with cutaneous lesions; that the specific 
character of the disease is not betrayed by any specificity of ele- 
ments or of their arrangement ; and yet that every pathological 
process of syphilis bears the imprint of the malady whose influ- 
ence it acknowledges. Here is a lesson certainly confirmed by 
clinical facts. With the possible exception of the gumma, there 
are no cutaneous lesions of syphilis which are peculiar to itself, 
and yet there are certain modes of behavior by which each, 
when carefully studied, betrays its identity. It is then by the 
modality rather than by any essential- character of the syphilitic 
process, that it is to be differentiated from all others. 

The papule, the tubercle, and the gumma may be regarded as 
typical pathological developments of the disease, as they cer- 
tainly constitute the basis of its common and important cutane- 
ous' manifestations. One of them indeed, the gumma, may de- 
velop in any organ of the body other than the skin. Under 
the microscope, these lesions are seen to be made up of a new 
growth whose numerous, small, rounded, or spindle-shaped ele- 
ments, whether derived from connective tissue or outwaudered 
leucocytes or both, and whether found, as they may be, in the 
rete, the corium or the subcutaneous tissue, very probably repre- 
sent transformation of protoplasm previously existing, or result- 
ing from embryonal metamorphosis of such pre-existing ele- 
30 



466 DISK ASKS OF THE SKIN. 

ruents. Kaposi well summarizes the chief peculiarities of this 
new growth, by remarking: First, that its elements are dis- 
tinctly circumscribed and homogeneous, differing, the minutest 
papule from the largest tubercle, only in respect to volume; 
second, that they arc inapt for permanent organization, but 
retrograde and disappear cither by resorption <>r by suppura- 
tion: third, that they arc remarkable for their tendency to 
coincident evolution and involution, usually in a centrifugal 
direction, the younger peripheral portions presenting the char- 
acters of recent infiltration, while the more ancient situated at 
the pathological centre, are earliest to disappear. 

This new growth naturally plays a more important part in 
some lesions than in others. Scarcely discernible in t lie hyper- 
senna of the macular lesions, and well defined in the papule and 
its modifications (the tubercle, the condyloma, and the forming 
gumma), it is represented in the vesicle, pustule, bulla, and 
degenerating gumma by either a fluid exudate composed of 
granular, cloudy, and nucleated elements, or by a sott, succu- 
lent, grayish, or grayish-red homogeneous mass, yielding a 
scanty juice, and not yet completely transformed by degenera- 
tion to the fluid condition. Beneath and about any of these 
last-named lesions, the circumscribed new growth may lay a 
foundation or erect a wall, which unmistakably asserts the unity 
of all such processes. 

Viewed comprehensively, the multiform developments of the 
syphilitic new growth are seen to be incontestably more rapid 
of evolution and involution than, in their average career, are 
all the neoplasmata. Myeloma (sarcoma) alone competes with 
it in this regard. Lepra, lupus erythematosus, lupus vulgaris, 
keloid, xanthoma, and the large majority of all forms of epithe- 
lioma outlive, as a rule, generations of syphilodermata. This 
relative rapidity of career has entailed upon the disease its pos- 
sibilities in the direction both of benignancy and malignancy. 
Whether, as it may, it destroy life, or, as may also be the case, 
it so slightly interfere with health as to well nigh pass unno- 
ticed, in either event the total period of its activity is relatively 
brief. 

Diagnosis. — The syphilodermata are to be distinguished from 
all other cutaneous eruptions by their general characteristics, 
and by the features peculiar to each lesion. It must not be for- 
gotten, however, that these lesions are not essentially different 
in character from all others, but are to be recognized with ease 
or difficulty, according as they do or do not betray the syphilitic 
expression. No one, however expert in diagnosis, can always 
trust himself to recognize these special features by a study of 
the eruption only, at a given moment of time. Neither in respect 
to color, form, size, situation, disposition, or other peculiarity, 
do the syphilodermata exhibit an absolute difference from the 
non-syphilitic affections of the skin. It is therefore requisite in 



SYPHILODEKM A. 467 

every case, to investigate in the fullest manner, the history of 
the disease, of all prior skin lesions, of a primary sclerosis (when 
this can be obtained), of adenopathy, miscarriages, abortions, 
and disorders affecting other organs of the body, such as the 
bones, viscera, organs of sense, and the mucous surfaces. Often 
a single extra cutaneous fact will be a valuable aid in establish- 
ing the diagnosis of syphilis. An "eczematous" infant, with 
the snuffles and a hoarse cry, has been treated in vain by many 
a physician, otherwise capable of making a diagnosis, who might 
have been given a clue to the nature of the disease from which 
the child was suffering, if he had taken the pains to inspect the 
anus and question the father in private. 

I deem it very necessary in this connection, to lay stress upon 
the well-known fact, that every syphilitic patient with a disease 
of the skin, does not necessarily exhibit syphiloderinata. The 
course of the disease is in many cases so protracted that patients 
have ample opportunities to contract other disorders; and their 
number is larger than is commonly supposed to be the case. 
They suffer most often from the medieamentous eruptions, espe- 
cially those induced by the ingestion of the iodide of potassium 
(q. v.); are, like other men and women, bitten by bugs and lice ; 
and suffer from eczema, acne, psoriasis, and other non-venereal 
disorders. This is less true possibly of the innocent victims of 
the disease, than of those guilty of sexual excesses, in and out 
of the married state, many of the latter leading the most disor- 
dered lives, and exposing themselves to the ordinary causes of 
disease to a degree not noted in other cases. 

It is always necessary, therefore, in making a diagnosis in a 
case supposed to be syphilitic, first, to determine ab origine, the 
fact of syphilis, and if that fact cannot be indubitably deter- 
mined, to be careful that the statements of the patient be not 
allowed to bias the judgment in pronouncing upon any eruption 
present. Second, supposing that such fact be established by 
clinical proofs without reserve, to determine whether the erup- 
tion present is produced by the existing syphilis or some other 
externally or internally operating cause, and if this last be deter- 
mined, to be careful in eliminating the syphilitic influence from 
its operation. 

Ignored syphilis is usually severe; but it is without avail that 
disorders of a different character are treated by the methods 
useful in the former. Thousands are annually so mistreated, 
who might be spared such a course. The frequent occurrence, 
after a suspicious exposure, of a balanitis, an attack of progeni- 
tal herpes, uninfected excoriations, blennorrhagic discharges, and 
even the appearance of molluscous tumors, warts, and parasitic 
cutaneous disorders upon the genital region, is a source of alarm 
and of fruitful error to the many rather than to the i'ew. 

On the other hand, the diagnostician must be ever on the 
alert to recognize the symptoms of the disease in those who 



468 DISEASES OF THE SK1X. 

least suspect it. Thus married women complaining of a " humor 
of the blood," men who have been "over-heated and broken out 
with a rash/' and a long list of patients exhibiting upon their 
persons the Bymptoms of -salt, rheum," "tetter,"" -scrofulous 
ulcers," and "erysipelas," are those whose speedy relief will de- 
pend upon the skill of the practitioner in recognizing exactly 
the precise na1 ure of the malady. 

The diagnosis <>f the syphilitic lesions of the skin is a matter 
of the very greatest importance, inasmuch as the health, com- 
fort, mental happiness, and domestic relations of thousands of 
men and women annually depend upon it alone. An error in 
either direction may involve the most serious consequences to 
both physician and patient, lie is hut poorly qualified to dis- 
charge the important duties of a general practitioner of medi- 
cine, who has not carefully trained himself to establish the 
truth in these cases, irrespective of the diagnosis of the patient 
and of all others who may have been consulted. 

Treatment. — The syphilodermata are to be treated by topical 
applications intended to hasten their disappearance or involution, 
hut as local manifestations of a constitutional disease their man- 
agement is largely that which looks to the relief of the latter. 

The treatment of syphilis will, in the pages which follow, be 
described in outline, so far as it relates to the relief of the cuta- 
neous lesions and of the systemic condition. The important 
modifications of therapy which are required in the management 
of syphilis of the osseous and nervous systems, of the respira- 
tory, gastrointestinal and other organs, it is scarcely necessary 
to remark, are fully described in the standard treatises specially 
devoted to this subject. Among them may be named, as of 
American authorship, the sterling works of Bumstead and Tay- 
lor; 1 of Van Buren and Keyes ; 2 and of E. L. Keyes. 3 Of those 
more or less recently published abroad, may be named the stand- 
ard treatises of La ncereaux; 4 of Jullien; 5 of Fournier; 6 of Diday 
and Doyon ; 7 and of Zeissl. 8 

The first and often the most important consideration for the 
practitioner who is in face of a syphilitic patient, is the care of 
that patient's general health. Simple and natural as it may be 
to set down such an injunction in this connection, its importance 
rests upon the fact that it is too often neglected. Patient and 
physician are often respectively hurried into the precipitate or- 

1 The Pathology and Treatment of Venereal Diseasi 3, Philadelphia, 1879 

2 A Practical Treatise on the Surgical Diseases of the Genitourinary Organs, 
including Syphilis. New York, 1874. 

• The Venereal Diseases, etc., New York. 1880. 

4 Trait-' Historique et Pratique sur la Syphilis. Paris, 1874. 

6 Traite Pratique des Maladies Veneriennes, Paris, 1879. 

6 Leqons sur la Syphilis, etc., Paris, 1ST:!. 

7 Therapeutique dee Maladies Veneriennes, Paris, 1876. 

8 Lehrbuch der Syphilis, etc., Stuttgart, 1875. 



SYPHILODERMA. 469 

dering and swallowing of specific drugs, without regard to other 
as important details. 

I am in the habit of handing to the patient at the outset of 
all treatment for syphilis, a slip of paper on which are printed 
in concise and simple terms, a set of rules which he should ob- 
serve during its continuance. For physicians who do not take 
similar precautions, it is advisable to enter rather fully into the 
explanation of certain details which the patient should be made 
to understand. 

He or she, if an adult, should, as a rule, be informed of the 
nature of the disease recognized, since every infected patient 
has an interest in knowing such fact, and it has an important 
bearing upon his or her relations to the uninfected. To every 
such person, with the assurance that the disease is often benign 
and productive of little discomfort and in any case curable, it 
should be stated that the affection is contagious and capable of 
transmission to sound persons by physical contacts of various 
character. The patient should be instructed as to the nutritious 
character of the diet lie should select, and should be informed 
that an increase in weight while subjected to treatment, is de- 
cidedly favorable in the matter of prognosis ; that the starving 
and sweating processes so highly esteemed by the charlatan and 
the advocate of the virtues of the waters of certain resorts, are 
relics of antiquity as useless in fact as they are frequent sources 
of peril. 

The bathing of the body is a matter of importance. Hot, 
Turkish and Russian baths are, as a rule, to be interdicted, inas- 
much as they tend to invite cutaneous hyperemia and thus to 
favor the occurrence of eruptions. Cool or tepid baths are to 
be employed sufficiently often for the purposes of cleanliness, 
and by tne sponge rather than by immersion. Dry friction of 
the surface of the body daily, may be ordered with advantage 
where the skin is still sound. The teeth, mouth, and gums 
require constant care. The use of the tooth-brush with cool 
water twice daily is a matter of importance, to be preceded for 
a time when the gums at the outset are in a tender, fungous or 
hsemorrhagic state, by gentle friction with the finger covered by 
a handkerchief dipped in a weak spirit and water lotion, to 
which the tincture of cinchona and of myrrh may be added in 
any desired proportion. Tobacco in every form is, without any 
question, decidedly injurious. Often the patient should be sent 
early to a competent dentist for the extraction or filling of carious 
teeth, and the removal by the file or dental engine of all sharp 
projecting edges. 

Malt liquors, wines and spirits should be employed, solely 
under the explicit direction of the physician. They are exceed- 
ingly useful in debilitated subjects of a certain class; and need 
not be unnecessarily prohibited in toto to those long habituated 
to their use. At the same time, an improper use of such stim- 



470 D 1 8 K A 8 ES O F T H E SKI N. 

ill ante is, it need not be said, in the highest degree harmful. 
When employed at all, they should be rigidly restricted to the 
dining-table ami the hours or" meals. 

A compliance with the laws of hygiene is even more requisite 
for the syphilitic than the non-infected. Fresh air. social amuse- 
ments, exercise, the regular routine of business life, or, when 
this has proved exhausting, the recreation of travel —the claims 
of all these need at times to he urged by the physician. With 
this the patient should he encouraged to free his or her mind 
from needless anxiety, and to avoid particularly the company and 
conversation of those similarly infected, whose opinions are 
based too often upon ignorance, or a knowledge of half truths. 
The literal nre of syphilis is, for a similar reason, to he eschewed, 
as the mass of patients, too many of whom purchase treatises on 
the Bubject, are able only to glean imperfectly the meaning of 
the authors cousulted. 

I have long made it a rule to urge married patients to frankly 
inform the partner of the fact of infection, for the sake of both; 
When this advice is followed, much trouble is avoided for 
the future, and one of the obstacles to a completely favorable 
issue is at once set aside. In my professional experience many 
instances have occurred in which the disruption of the conjugal 
bond resulted from infection of one, hut usually of both parties; 
but I regard it as a striking argument in favor of the policy 
here urged, that in this entire experience there has been no 
single instance in which a frank and honorable confession has 
been followed by such a consequence. It should he added, that 
in no one of the kt confessed" eases, has there been subsequent 
infection of the innocent. It need scarcely be said that the 
larger number of these patients have been husbands. Recently 
intected young adults who have contracted a marriage engage- 
ment, should invariably claim release from such a tie, for the 
sake of all concerned. The syphilitic nurse must he taken nt 
once from the sound nursling; and the child with hereditary 
syphilis he suckled only by its own mother. The latter, accord- 
ing to the law of Colles, the exceptions to which are so few as to 
prove the rule, always enjoys immunity as against the diseased 
mouth of her own child. 

Turning to the consideration of the medicaments employed 
in syphilis, it is to he remarked at the outset, that there is no 
routine plan of treatment which in every case can be advan- 
tageously employed. In no respect do physicians so differ from 
each Other, judged by the standard of professional skill, as in 
their ability to use a single remedy with success. He who has 
the largest armamentarium, is not always either the best equipped 
or the most successful. Mercury, iodide of potassium, iron, and 
quinine, are the great remedial agents in syphilis, but they may 
also be used vainly by one man in the long effort to accomplish 



SYPHILODEKMA. 471 

that which another achieves speedily and brilliantly by use of 
the same remedies, employed with greater skill. 

Of the other substances vaunted as either advantageous or 
specific in the treatment of the disease, no one possesses any 
claim whatever to the confidence of physicians. Sarsapari.il a, 
dulcamara, stillingia, guiacum, tayuya, mezereon, and the long 
list of other vegetable preparations whose virtues have thus 
been extolled, are all as harmless in themselves as they are in- 
effectual for the relief of the malady. 

Before proceeding, however, to assume the responsibility of 
directing a course of treatment for syphilis with remedies of 
acknowledged value, the physician will do well to remember 
that no two cases of the disease are precisely similar, and that 
there is the widest, range between the most benignant forms 
encountered in private practice and the malignant cases that are 
seen in hospital wards. Some forms of the malady are so abso- 
lutely mild as to constitute an inconvenience merely; others so 
severe as to destroy life. It is an axiom in venereal disease, 
that more patients perish annually from blennorrhagia and its 
results, than from syphilis. There could be no greater error 
than to treat any disease exhibiting so wide a variation in 
severity, by a uniform method. 

Mercury, after the assaults upon it of generations of men of 
admitted wisdom and candor, stands to-day unrivalled as a 
remedy for the relief particularly of those stages of syphilis in 
which the skin is involved. Administered with skill, it can be 
given for years at a time with immense advantage to the syphi- 
litic, who, during a well-regulated mercurial course, should gain 
in weight, improve in vigor, and exhibit a healthier color of the 
skin. No competent physician of today employs it in such a 
manner as to induce salivation, or any other of its toxic effects. 
During the last twenty years I have had the opportunity not 
merely of making large use of this drug in my own practice, but 
of seeing many patients treated by other physicians in a similar 
way. In about a dozen cases I have observed excessive toxic 
effects of the remedy, and in each have had reason to believe 
that the carelessness or ignorance of the prescriber was respon- 
sible for the result. It should be remembered that in every 
discussion of the merits of mercury in syphilis, both physicians 
and patients have been guilty of the ignorance or folly of ascribing 
to the remedy the disastrous effects of the disease. 

Mercury may be given by the mouth, by inunction, by subcu- 
taneous injection, or externally by the aid of the vapor bath. 
Decidedly the most popular method, and that productive of 
least inconvenience to all concerned, is the method by ingestion. 

I may remark here briefly, without occupying space in setting 
forth the reasons for such a statement, that I believe, in the 
treatment of syphilis, the use of the mild chloride, corrosive 
sublimate, and bicyanide of mercury, together with blue mass, 



472 DISEASES OF THE SKIN". 

ie in general to be deprecated. These preparations are all less 
adapted than others tor continued employment during long 
periods of time, and are open to tlie objection of either readily 
undergoing rearrangement into more stable compounds of the 
metal, or of producing undesirable irritative effects. With the 
protiodide and biniodide of mercury, an impression can he pro- 
duced upon the system which can be readily proportioned to 
the exigencies arising in every ease, which can be sustained 
during that "chronic medication'' which Fournier declares to 
be requisite in every chronic disease, and which can be exerted 
without tear of immediate or remote deleterious consequences. 

Treatment of syphilis by the mercurial selected for use, should 
as a rule be begun only at the moment of* evolution of constitu- 
tional symptoms. The initial sclerosis of the disease is, to a 
remarkable extent, amenable to the action of the metal, but in 
the large proportion of eases will cicatrize, when in an ulcera- 
tive Btage, without having recourse to general medication. The 
hitter may be well reserved, as suggested by Bumstead and Taylor, 
tor such primary lesions as are threatening in symptoms, and for 
such individuals as require or demand speedy cicatrization of 
their chancres, as, for example, those about to travel beyond the 
reach of medical assistance. My personal experience has fully 
confirmed the wisdom of the teaching which reserves specitic 
medication, till the second period of incubation lias passed. No 
local or general treatment can avert either a mild or severe 
explosion of symptoms after that period is completed. In the 
experiments made by myself in order to determine this point, I 
have noticed either the production of strikingly irritative effects, 
such as very marked relapse, or unusual increase in the volume 
of the initial sclerosis immediately before the evolution of the 
first syphilodermata, or a distinct obstinacy in the latter to the 
action of the medicament employed. 

In the early stages of syphilis in adults, I regard the protiodide 
of mercury as the most trustworthy of preparations. Of all 
classes of adult patients, including strong males and delicate 
females, there are scarcely two per cent, who cannot take it, if 
the dose be proportioned to the individual susceptibility. It is 
usually administered in [till form, in doses of one-fifth (.01), 
one-fourth (.016), or one-third (.02:2) of a grain, three times daily, 
combined with the extract of gentian. The dose may be grad- 
ually increased, according to the necessities of the ease, from 
one-half (.032) to three (.266), and even four (.266) grains in the 
twenty-four hours. Many of the gelatine-coated pills found in 
the market contain accurately divided doses of the salt. The 
sugar-coated pills of Messrs. Gamier and Larnoureux, containing 
each one centigram of the protiodide, are efficient, and largely 
employed. 

Commencing with a minimum dose, the remedy is to be 
steadily exhibited, and the daily quantity consumed vevy grad- 



SYPHILODERMA. 473 

dually increased, till the degree of tolerance of which the pa- 
tient is capable, has been ascertained. Should the stools become 
frequent, pain be excited, or a slight effect be produced upon 
the mouth, such as is indicated by a metallic taste, moderate 
increase in the quantity of saliva, or any noticeable degree of 
tenderness of the gums, the dosage is to be gradually dimin- 
ished till these symptoms disappear. Often the withdrawal oT 
a fifth (.01) or a half (.033) of a grain daily, will suffice to enable 
the patient to tolerate the quantity thus diminished. The medi- 
cation is to be faithfully continued till the object in view is 
obtained, viz., relief of all symptoms of the disease. 

Keyes' well-known, so-called " tonic treatment of syphilis" is 
based largely upon the plan whose outline is merely sketched 
above. By the method, which this author has certainly popu- 
larized, the dosage is increased only on each third or fourth 
day, till irritative effects are produced, when, after an interval 
of two days, the quantity taken at the time of the production 
of such effects is reduced one-half to one-third. This reduced 
quantity is termed the " tonic dose," and is thereafter continued 
throughout the treatment in " nearly all conditions of health or 
disease." 1 

This method of treatment is in many cases admirably effective 
and is eminently safe. Still, viewing the suhject w T ith the con- 
servatism which its importance justifies and which a mass of 
clinical facts demands, it may be well doubted whether it is 
always proper to administer a mercurial for weeks at a time to 
a man in apparently good health. With the active measures at 
immediate control in the mercurial vapor bath, it is usually safe 
and not unwise to temporarily suspend specific medication of 
the patient who exhibits such amelioration of symptoms as to 
be tree from external manifestations of the disease. Every 
syphilis has its periods of activity and repose. Such an hour 
of repose will be well employed in administration of iron, which, 
as tending to relieve the distinct chloro-anaemia of the disease, 
has its claims to recognition in the list of ''specific" remedies. 
No case of syphilis can be said to have been properly treated, 
in which this remedy had not been given for at least a part of 
the time during which the patient was under observation. The 
citrate of iron and quinia is an excellent preparation for this 
purpose, administered at'the meal hours, in a small quantity of 
sound sherry wine; or the iodide of iron may be employed in 
syrup, or in the pills made by the formula of Blancard. In 
other cases, the muriated tincture may be employed, but the 
physician will always be cautious about ordering an acid pre- 
paration of any kind, during the intervals of a mercurial course. 

1 Consult the interesting paper of the author in the American Journal of the 
Med. Sci., January, 1876; also his latest exposition of his views in the Phil. 
Med. Times, Nov. 25, 1882, p. 337. 



474 DISEASES OF THE SKIN. 

There is no form of anaemia which responds more promptly to 
the chnlybeatea than dues that produced by the syphilitic virus. 

The biniodide may be substituted for the protiodide when, for 
any reason, it may be thought desirable, commencing with a 
minimum dose of one-sixty -fourth ofa grain i .001), and increasing 
this gradually to one-fortieth (.0016), or rarely to one-twentieth 
(.0033), either in pill or solution. The average dose of one-for- 
tieth (.0016) of a grain in pill form, administered three times 
daily. BOOH after eating, is tolerated by the majority of all patients 
of both sexes without consciousness of unpleasant effects. 

For those who prefer to use the rather more active and cor- 
respondingly dangerous salts of the metal, calomel may be ad- 
ministered in one or two grain doses (.006-133) three times 
daily, in combination with an opiate to prevent its action on 
the bowels, or, as recommended by Peters, in one-tenth (.0066) 
of a grain dose every hour. Small doses of blue mass or gray 
powder may also he employed. According to the traditions of 
the profession, the gray powder is most suitable for children and 
infants, but since the frequent discovery in the latter of the cor- 
rosive chloride, either as of early or late chemical production, it 
is less esteemed. The homoeopathic first decimal trituration of 
calomel with sugar of milk, is a far more suitable compound. 
Corrosive sublimate in doses of from one-twentieth (.0033) to one- 
twelfth (.005) of a grain is exhibited in the pill form or in solu- 
tion ; and is probably more generally employed in the treatment 
of syphilis than any other mercurial salt. The objections to its 
use are suggested above. Though constantly ordered by me in 
the public Charities of the city, where it is furnished as a cheap 
and a convenient substitute for the more elegant preparations in 
the market, I have not in five years ordered a single dose of it 
for a syphilitic patient in private practice. When given in 
solution, it produces a disagreeable metallic taste in the mouth, 
which some patients can perceive after the lapie of six hours. 

With many authors of wide experience, it is customary to 
employ opium, either alone or in connection with the use of 
mercury, for the relief of ulcerative or other lesions of syphilis. 
Sometimes it is employed for the purpose of relieving pain, 
sometimes to prevent the cathartic action of the metal upon the 
bowels, and again because it is supposed to possess some power 
of arrest over the destructive action Of the disease. It should 
never be exhibited when by reducing the mercurial or exchang- 
ing the latter for a ferruginous dose, the same result can be 
reached. No syphilitic patient is in the end hastened to the 
desired termination of his disorder, by the use of a remedy 
which interferes with assimilation and digestion; and such a 
remedy is opium in all its forms. Temporary advantage may 
at times be gained by its employment, but this is usually more 
than counteracted by its ultimate effect upon the gastrointesti- 
nal tract. 



SYFHILODERM A. 475 

Mercury is also satisfactorily introduced by the method of 
inunction. The metal, when thus employed, is readily ab- 
sorbed by the system, and its therapeutic value is then no less 
evident. Inunction should be employed in every case which 
admits of it, since the gastro-intestinal tract is thus left undis- 
turbed, and, further, the dose of any needed chalybeate or the 
iodide of potassium -per orem, can be regulated without increas- 
ing or diminishing the quantity of mercury in daily use. Mer- 
curial ointment is commonly used for this purpose, but a much 
more cleanly substitute for it, is provided in the oleate of mercury 
in the strength- of ten, fifteen, or twenty per cent. There is but 
little question that the oleate also is somewhat more readily 
absorbed from the surface of the skin. The ten per cent, oleate 
is employed by me in preference to the stronger preparation, as 
less liable to irritate the surface of the skin. From half a 
drachm to a drachm (2.-4.) of either the ointment or the oleate 
can be rubbed into the skin at night before retiring, and the 
part selected for inunction cleansed by washing in the morning. 
Both, if continuously applied to a single portion of the skin, 
are liable to produce a mild local dermatitis or eczema, and 
hence it is wise to select on successive evenings a fresh portion 
of integument for the local application, preferably that where 
the epidermis is relatively thin, as, for example, the flexor 
aspects of the joints. The patient can thus upon one evening 
anoint the internal faces of the thighs; upon the next, the sides 
of the chest; upon another, the loins, etc., taking care to avoid 
surfaces where an induced eczema is likely to prove especially 
annojing, such as the scrotum, the axillfe, and the groins. The 
oleate may in some cases be well rubbed into the soles of the 
feet previously soaked in warm water, after which the socks or 
stockings may be drawn over the feet for the night. In the 
case of infants, the inunction is well performed by the natural 
movements of a child, if a flannel swathing-band previously 
smeared with the oleate be wrapped about its belly, so that the 
mercurial comes in contact with the skin. Should local irrita- 
tive effects be produced, these subside rapidly, as a rule, after a 
warm alkaline ablution followed with a bland dusting powder. 
Subsequently or even before such accident in the case of infants 
or patients having unusually sensitive skins, the oleate may be 
mixed with equal parts of vaseline, lard, or olive oil. As some 
patients become disgusted with this routine, it is well at the 
onset to flavor the substance selected for inunction with laven- 
der, rosemary, or bergamot. 

It is my conviction that in this country too little attention 
has been attracted to the treatment of syphilis by mercurial in- 
unction; and I desire to call especial attention to the fact that 
the preceding paragraphs which relate to the use of mercury by 
the mouth are to be understood as related in all cases to the 
employment of the metal by the skin. It is my custom to order 



476 DISEASES OF THE SKIN. 

inunction in all practicable cases; to Bave the stomach as much 
as possible; to continue with the oleate nightly, weekly, or less 
frequently so long as there is danger of relapse ; and to carefully 
adjust the quantity employed to the exigencies of every case. 
In this manner I have succeeded in relieving patients of all 
symptoms of the disease who have not during their treatment 
swallowed a single dose of mercury, and the permanency of 
whose relief I have tested during years of subsequent observa- 
tion. 

One of the most effective methods of administering the metal 
is by fumigation, in the mercurial vapor bath. It is employed 
by many syphilologists as the sole means of exhibiting the mer- 
curial selected for use, but is, for the average of American 
patients, too inconvenient for continuous employment. It is 
regularly employed by me, first, in all cases where the earliest 
Byphilodermata are intense, generalized, and particularly con- 
spicuous upon the face; second, in all obstinate cases where the 
patients are not women nor cachectic subjects of either sex; 
third, at the outset of many "ignored" cases, where the syphilo- 
dermata, either more or less generalized, have proceeded to un- 
interrupted evolution; fourth, in the severe cases of patients 
coining from the country to the city, and able to remain but a 
brief time within reach of the advantages offered in the metro- 
politan centres. From half a drachm to a drachm (2.-4.) of 
calomel, metallic mercury, the bisulphuret, the black oxide, or 
the hydrargyrum cum creta may be employed for each bath. I 
am in the habit of using from a scruple to a drachm each (1.-4.) 
of calomel and cinnabar. The patient is stripped of his clothing 
and seated in a chair, the patient and chair being completely en- 
veloped in blankets, which are closely fastened at the neck of the 
bather. Beneath the chair is an alcohol lamp, surmounted by a 
tin vessel of water in ebullition, the hot vapor of which in a few 
moments induces copious perspiration. When this result is ob- 
tained, the lamp is brought beneath a metal plate containing the 
substance to be volatilized. The patient remains exposed to the 
vapor for about ten minutes after this process of sublimation is 
finished, and retires at once to bed without cleansing the skin, the 
fumigation being preferably conducted before the hour of sleep. 
In the morning, a bath may be taken for the purposes of clean- 
liness. It is more convenient in the generation of the vapor in 
this way, to make use of Mr. Henry Lea's safety fumigating 
lamp, but the materials requisite for the production of all 
desired effects, with the exception of the alcohol lamp, can be 
procured of any good tinsmith. In the city, 1 frequently send 
male patients to the bath houses, where the fumigation is con- 
ducted in the daytime; and have thus far in no instance noted 
unpleasant effects, such as are popularly associated with "taking 
cold" after exposure to the action of mercury. In most of these 
establishments, provision is made so that the head also can be 



SYPHILODERMA. 



477 



exposed to the mercurial fumes, respiration being conducted 
through a tube in connection with pure air, a provision useful 
in certain cases of emergency ; and I might add that only " emer- 
gency cases" should be required to resort to such measures. 

Fiff. 50. 




Lea's lamp for fumigation. 

The happy effect of the mercurial vapor bath is often marvel- 
lously rapid. I have seen a generalized syphiloderm become well- 
nigh indistinguishable upon the surface after four baths at inter- 
vals of two days each. With this potent agency at hand, it can 
be well understood how the skilled physician can afford to watch 
his syphilitic patient from week to week, taking a dose of iron 
internally and employing inunction externally, the few lesions 
fading slowly from the surface, all fears quieted, and the nutri- 
tion sustained at a high grade. In comparison with this com- 
bined method, the swallowing of blue mass, or calomel and 
opium, should be regarded as a more clumsy and dangerous 
procedure. 

The hypodermic injection of mercury, largely popularized by 
Lewin, 1 though very frequently employed in Europe in the 
treatment of syphilis, is open to the serious objection of re- 
quiring the aid of the physician for the administration of each 
dose. It is an efficient, speedy, and safe method, but will prob- 



1 Die Behandluna; der Syphilis mit Subcntaner Sublimat-Injection, Berlin, 
1869 ; also translated by Prcegler and Gale, Phila., 1872. 



4<S DISEASES OF THE SKIN'. 

ably always find largest favor in the treatment of patients in 
hospital, who are there completely subject to the orders of their 
medical attendant. Ar the site of the injections, too, not rarely 
sses have formed. One-twelfth (.005) or one-eighth of a grain 
of corrosive sublimate, dissolved in ten or fifteen mini run 
<>t' water may be injected at a time, the operation being repeated 
upon about twenty occasions. Bamberger, of Vienna, has re- 
ported favorable results after the injection of an albuminate or 
a peptone of mercury, thus attempting to avoi I the danger of 
localized abscesses, and insuring speedy absorption of the metal. 
All forniuhe. however, proposed for preparation of solutions of 
this character have hitherto been imperfect, both in consequence 
of failure to obtain a pure mercuric albuminate, and also from 
failure of permanency in the solution. Staub's formula, the 
result of the experiments made by Hepp, 1 may he taken as a 
sample of the rest : — 

Hydrarg. chlorid. corros. gr. xviij ; 1 25 

Amnion, chlorid. gr. xviij; 1 25 

Sod. chlorid. 3j ; 4 15 

Aq. dest. f^iv ; 125 00 

Dis?olvo. filter, and add the white of one egg in distilled water sufficient to 

make 1 125.) 31V ; fifteen minims of the solution contain about one-twelfth of a 

grain (0.005) of the sublimate. 

Ptyalism, stomatitis, fetor of the breath, or a fungous condition 
of the gums with inappefence and other characteristic symp- 
toms of the ill effects of mercury, including all grades of gas- 
trointestinal disturbance, are rarely seen in modern practice, 
and should never he permitted to occur in a properly regulated 
mercurial course. When they are produced, the tongue pro- 
jected from the mouth is usually tumid, and exhibits at its 
lateral borders the imprints of the inner faces of the molar teeth. 
Its surface is also covered in various degrees with a thin, dirty- 
grayish coat ; and the odor of the breath is peculiarly offensive, 
being often noticeable at the distance of several feet from the 
patient. In such eases, the food should he liquid and nutritious ; 
hot and cold drinks alike should he scrupulously avoided ; and 
the mouth frequently cleansed with washes containing dilute 
liquor sodas chlorinate, or the chlorate of potassium, or very 
weak carbolic acid in solution. Internally, the citrate of iron 
and quinia may he often used with advantage; and, in particu- 
larly severe eases, the chlorate of potassium to the extent of a 
drachm (4.) daily. The compressed tablets of this salt, each 
containing five grains (0.34), are available for this purpose. 
heing slowly dissolved in the mouth, the medicated saliva and 
mucus heing then well diffused over the inflamed buccal mem- 
hrane, tongue, and fauces. The mercurial is to he suspended in 
all cases, and ice 1 water to he interdicted, gangrene having lol- 

1 Traitement de la Sylph, par lea Inject. Hypoderm. de Sublime. These de 
Paris, 1872. 



S Y P H I L O D E R M A . 479 

lowed its use in a few cases. In milder forms, the tincture of 
myrrh and of cinchona, diluted with sweetened water, or honey 
and water, will be sufficient for local medication of the mouth. 

Iodine is chiefly employed in syphilis in the form of the iodide 
of potassium. It possesses some value, without any question, 
in every stage of syphilis, and is thus indiscriminately used by 
many practitioners. Its value, however, in late secondary and 
tertiary, is incontestably greater than in earlier lesions of the 
disease, and its use should be largely restricted to the particular 
periods in which these manifestations appear. Every prudent 
physician will hesitate before ordering for a disease exhibiting 
cutaneous lesions, a remedy which will positively produce cuta- 
neous lesions in the majority of all patients ingesting it. In 
this connection the reader will do well to consult the chapter on 
dermatitis medicamentosa, in which the various eruptions pro- 
duced by this drug are recorded. Thoughtful men are begin- 
ning, in the light of the present knowledge upon this subject, 
to ask, to what extent the syphilodermata have been in the past 
aggravated or obscured by this remedy. He would be indeed 
bold who would attempt to prove that the medicamentous 
eruptions thus excited have not, in the past, figured largely in 
the catalogue of the syphilodermata. 

On the other hand, the value of the remedy, properly ad- 
justed to the age and other conditions of the disease, is more 
than incontestable, it is peerless in its special field. Whether 
given alone; or by the so-called "mixed" treatment in combina- 
tion with mercury ; or administered internally while a mercu- 
rial is introduced by the skin; or exhibited, lastly, by alterna- 
tion with the metal, in each it finds a special value, and may 
be simply indispensable. It may be given in doses of from live 
grains (0.33) to a drachm (4.) three times daily after eating, well 
diluted with water. The larger doses should be invariably 
reached gradually; should never be employed except by special 
order of the physician and when the patient is within easy 
reach of the latter; and should always be ordered with the 
understanding that the patient should diminish or suspend the 
treatment in case of unpleasant results. The symptoms of 
iodism, other than the production of cutaneous lesions, such as 
coryza, oedema of the lids, and faucial irritation, are apt to be 
the result of the first few doses ingested, and often bear no 
relation to the size of the latter. One or two grains (0.66-.133) 
will, in certain cases, be sufficient to produce the most disagree- 
able effects which, if they are observed before the remedy be 
suspended, may not return with even the largest doses. In a 
few cases, the iodide of potassium produces violent toxic effects 
in any dose, owing to exceptional idiosyncrasy. I have met 
with several such cases, and have one gentleman now in my 
charge suffering from an ulcerative tubercular syphiloderrn of 
the nose, who is quite unable to swallow the drug in any form. 



480 DISEASES OF THE SKIN. 

Both the chloride of ammonium and carbonate of ammonium 
are recommended for use in combination with the iodide of 
potassium, as increasing its efficiency. The iodides of sodium, 
ammonium, and lithium possess also, without question, some 
influence over the disease, but have in my hands proved less 
efficacious than the potassium salt. Of the three named above, 
I have found the iodide of lithium to he most prompt in its 
effects. 

There is no combination of mercury with the iodide of potas- 
sium which is employed by me more frequently than the well- 
known "siropde Gibert," which though first popularized in the 
St. Louis Hospital of Paris, has been since extensively employed 
in this country. It has been slightly modified to suit the vary- 
ing tastes of many surgeons. I generally order it in the follow- 
ing formula : — 

R. Hydrargyri biniodid. gr. ss-ij ; 033-13 

Potass, iodid. 31J— viij ; 8-32 

Gentian, syrup. 1 

(vol syrup, glycyrrliiz.) J- aa f§ij ; G4 

Aq. dest. j M. 

Dose. A teaspoonful in water after eating. 

The syrup of liquorice disguises the taste of this combination 
more completely than other syrups I have used. With the 
dosage carefully regulated, a few drops (ten to fifteen) may be 
administered with advantage to children. 

The following are indications for the use of the iodide of 
potassium either alone or by the so-called " mixed" method in 
the treatment of syphilodermata : The occurrence ^1) of late, 
tubercular, gummatous, or ulcerative lesions; (2) of formidable 
symptoms in other portions of the body concurrent with early 
or late, mild or severe syphilodermata, as, for example, grave 
ulcerations of the velum or fauces with a symmetrical macular 
eruption, or coincidence of a generalized pustular or papular 
syphiloderm with herniplegic, aphasic, optic, or renal complica- 
tions; (3) of early or late manifestations which either assume 
the so-called "galloping" type, being rapidly succeeded by more 
and more formidable symptoms, or which exhibit the capricious- 
ness of the disease in a reversal of the usual sequence of evolu- 
tion, as, for example, when symptoms usually counted as late 
phenomena, occur within a few weeks after infection and are fol- 
lowed by ttie early symmetrical rashes ; (4) of early or late symp- 
toms occurring in cachectic, strumous, or otherwise debilitated 
patients. I have treated eleven tuberculous patients infected 
with syphilis; and this experience has led me to believe that in 
all such cases it is imperative to dispense with every mercurial 
dose possible. Mercury is assuredly not a tonic in tuberculosis 
commingled with syphilis. 

The local treatment of the initial sclerosis of syphilis by com- 
plete excision, lately revived by Auspitz, has been practised 
since the date of his paper in 1879, by Kolliker, Zeissl, Leloir, 



SYPH1LODEKM A . 481 

Chadzynski, Mauriac, and others; 1 and the result has proved 
conclusively that such operative interference furnishes no bar to 
constitutional infection. Chancres should not be destroyed by 
caustic agents of any character, as the latter are liable to induce 
either irritative or inflammatory effects which may be followed 
by denser induration. Ointments, as a rule, are also objection- 
able, exception being made in the case of hemorrhagic lesions 
when the removal of an adherent dressing is followed by unpleas- 
ant consequences. Cleanliness with soap and water is of chief 
importance. After each local bath the parts may be dusted with 
a dry powder such as iodoform, calomel, zinc oxide, or starch; 
or dressed with a soft piece of lint saturated in the lotio nigra, 
or even better a spirit lotion containing tannin and carbolic or 
boracic acid. Opiated washes may be requisite in all painful 
and ulcerative lesions. When a phagedenic tendency is dis- 
played, deep cauterization may be required; and the subsequent 
local employment of solutions of the potassic permanganate, two 
to ten grains (0.133-.666) to the ounce (32.) of water. 

Local treatment of the syphilodermata may be demanded, 
either by reason of their appearance on exposed surface, such as 
the face and hands, or by reason of their obstinacy or threaten- 
ing character, as when they are ulcerating rapidly. Macular 
and papular lesions of the face may be treated by local applica- 
tions of the five per cent, oleate ; mercurial ointment, one to two 
drachms (4.-8.) to the ounce (32.) of cold cream or vaseline; the 
red oxide, two to four grains (0.133-0.266) to the ounce (32.); 
or the ammonio-chloride, half to one scruple (0.666-1.33) to the 
ounce (32.) of ointment. Lotions of the bichloride, one to two 
grains (.066-0.133) to the ounce (32.) of cologne, are also efficient. 
These preparations will be found much more valuable if used at 
night before retiring, and left upon the face during the hours 
of sleep. Each is well preceded by hot bathing of the face for 
several minutes, as in the preparatory treatment of the same 
region in acne papulosa, and. indeed the sulphur preparations 
employed for the relief of that disease, will at times be found 
useful also in the local treatment of the syphilodermata. 

The hot ablution is particularly useful in the treatment of 
the scaling and frequently fissured syphilodermata of the palms 
and soles, the pain of which in severe cases, is greatly alleviated, 
by this treatment. After the epidermis in these parts has been 
well macerated, the hands or feet should be thoroughly dried, 
and the mercurial, tarry, or other salve well rubbed in. The 
glove or stocking should be then drawn over the part. 

Secreting condylomata, flat papules, vegetations, etc., also re- 
quire bathing in soap and water, especially when situated at 
the mucous outlets of the body or on the scalp. When the 
secretion is offensive, carbolic acid, thymol, or chlorinated soda 

1 See Keyes' later communication on this subject, 1. c. 

31 



482 DISEASES OF THE SKIN 

should be added to the lotion. Cleanliness is indeed more essen- 
tial to the Bj'philitic patient, male or female, than to the healthy. 
After such cleansing or disinfecting ablution, the parts should 
he dressed with a powder, such as dry calomel, iodoform, bis- 
muth, the //mc oxide, salicylate of soda or stared). Vegetating 
lesions of t hese regions may require also pencilling with a crayon 
of the nitrate of silver. Ointments, as containing grease, are 
decidedly objectionable tor this purpose. 

('rusted and ulcerative lesions, large or small, are to be treated 
in accordance with general principles. Crusts should always be 
removed, either by the oil and soap and water treatment, or by 
the dermal curette, alter which the underlying ulcers should he 
thoroughly cleansed, pencilled with nitrate of silver, filled with 
powdered iodoform or calomel, or touched with a five to twenty 
per cent, solution of carbolic acid, ami then dressed with a dilute 
ointment of the nitrate of mercury, one to two drachms (4.-8.) 
to the ounce (32.). Large syphilitic ulcers are often encountered 
on the surface of the lower extremities, especially the legs, and 
in' this situation elastic compression by the Martin bandage will 
greatly accelerate their cicatrization. 

The syphilodermata are in general particularly amenable to 
the action of the mercurial vapor bath, which may he regarded 
as exerting upon them both a local and constitutional influence. 
Those existing upon the face are thus henefited by exposure to 
the metallic vapor in the " head-piece" arrangement already de- 
scribed. The patient may also less comfortably avail himself of 
the same local treatment, by holding the breath and exposing 
the head and face for a few minutes at a time to the fumes of 
the mercury beneath the blanket, in the plan descrihed as prac- 
ticable at the bedside. 

It is within reasonable bounds to say, that the syphilodermata, 
if treated locally by the measures described as useful in non- 
syphilitic* cutaneous affections of similar type, will always pro- 
ceed to a satisfactory involution, if the general treatment of the 
patient is at the same time skilfully ordered. 

Prognosis. — The prognosis of syphilis may be said to be in 
general favorable, the popular opinion on the subject being at 
variance with fact. Benignant syphilis may even disappear 
without treatment. Malignant forms of the disease may, but 
rarely do, destroy life. The element of treatment, both as to 
the character of the latter and the period of its continuance, 
enters more largely into the estimate upon which a prognosis 
rests, than in most other disorders exhibiting cutaneous symp- 
toms. The syphilis which is untreated, whether because of a 
failure to recognize its real character, or of ignorance, poverty, 
neglect, or extravagance in dissipation, is usually grave. The 
same may be said of syphilis occurring in strumous, tuberculous, 
and cachectic suhjects, those enfeebled by age, by other diseases, 
by chronic alcoholism, or by sexual excesses. Hereditary syphilis 



CHANCROID. 483 

is bjr far the gravest form of the malady, not merely because of 
the tender age of its victims, but also because the latter, at the 
earliest period of their lives, find themselves burdened by a dis- 
ease which may first attack organs essential to life. 

The majority of adult American patients 'sooner or later get 
rid of all active manifestations of the acquired disease, marry, 
and beget in the end sound children. 

Chancroid. 

This term has been very generally adopted in this country 
for the purpose of designating the virulent, local, contagious 
ulcer of the genitals, designated also as the "simple," " soft," 
"non-infecting" chancre, the chancrelle of French authors. It 
has no relation to syphilis, nor to the neoplasmata with which 
syphilis is commonly classified. As it is, however, a disease with 
which the initial sclerosis of" syphilis may be confounded, and 
is also, not merely a venereal lesion, but one which may be 
encountered upon the skin as well as the mucous surfaces, it is 
briefly described in this connection. 

Chancroids present as distinct a uniformity of feature as the 
lesions of vaccinia or of herpes zoster. They are thus stamped 
with special and readily recognized characteristics, differing in 
this respect from the various modes in which the first lesion of 
syphilis may declare its nature. The virus of the disease, for 
such it must be termed, is one s id generis, and derived exclusively 
from lesions of like character. That virus is contained in a puru- 
lent secretion, and is capable of transmission by inoculation and 
auto-inoculation. After such successful inoculation, there is no 
period of incubation. The results of experimental generation 
of the virus in human subjects, indicate that the pathological 
process which it awakens, can be determined within tvventj^-four 
hours after its introduction within the skin. At times, after 
accidental inoculation, eight and ten days elapse before the lesion 
of the disease is manifested, cases where presumably the virulent 
secretion has remained pocketed in the orifice of a follicle or a 
fold of mucous membrane, where its irritant effects have finally 
opened an avenue for its deeper ingress. When typically devel- 
oped, the chancroid is seen to be a pustular lesion, frequently 
multiple, of roundish outline, beginning as a pin-head sized, 
turbid, vesico-pustule, rapidly enlarging to a pea- or bean-sized, 
well developed, projecting, yellowish, globoid, elevation of the 
epidermis, filled with greenish-yellow r pus. When located in 
furrows or depressions of the surface, it may have a linear, oval, 
or even a dumb-bell shape, the latter in consequence of its exten- 
sion from a sulcus to overlying folds. 

Clinically, the roof-wall of this pustule is not frequently 
encountered, the lesions from the first exhibiting the ulcers from 
which the pustules described above invariably rise. These ulcers 



484 DISEASES OF THE SKIN. 

vary with flif shape of the superimposed pustules, being round- 
ish, ovalish, or linear, occasionally irregular in outline, with 
sharply defined or cut edges; uneven ] .us-bat lied floor; taint 
pinkish areola; supple, non-indurated base; abundant puriform 
Becretion ; and are accompanied by pain or not, according to the 
degree of inflammation present. In consequence of the auto- 
inoenlahility of the discharge, the ulcers frequently give rise to 
others in the vicinity, as when the prepuce lies in contact with 
chancroids of the glans. 

The ulcers thus presented usually attain an average size of 
a pea or bean in the course of from ten to fourteen days; then 
remain in an indolent and suppurative condition, showing no 
tendency to heal tor a fortnight or three weeks; and finally 
granulate, exhibiting the ordinary phases of repair ; the resulting 
cicatrix being transitory, or more often, indelible. In excep- 
tional cases, the ulcer spreads widely. In the groin, it may 
attain a diameter of several inches; its floor secreting scantily; 
its edges, lurid, undermined, purplish, or ragged ; its color, red- 
dish, bluish, purplish, or leaden ; fistulous tracts and sinuses 
filled with an ichorous sero-pus, radiating in dependent situa- 
tions; its base, densely indurated; its career, prolonged for years, 
and inducing finally a systemic cachexia not different from that 
observed in all chronic ulcerations of severe grade. In yet other 
cases, the occurrence of gangrene, or phagedena, changes the 
features of the lesion to those of other ulcers undergoing similar 
metamorphosis. 

Chancroids occur upon all exposed mucous surfaces of the geni- 
talia of both sexes, upon the integument of the penis, scrotum, 
labia, thighs, fingers, perineum, peri-anal region, and, very rarely 
indeed, upon the face. In consequence of its tendency to relapse, 
abundant contagious secretion, and auto-inoculability, it is more 
frequently encountered among the filthy, the poor,and the classes 
that frequent hospitals and dispensaries, than is the primary 
syphilitic lesion. Among the wealthy, the well-to-do, and the 
cleanly, this order of frequency is reversed. 

The chancroid ulcer is also much more frequently complicated 
by surgical accidents than is the infecting lesion of syphilis. 
This is partly due to the prevalence of an ulcerative type in 
all its manifestations, and in part to its situation. Thus it is 
often accompanied by severe inflammatory symptoms, which 
may be aggravated both by phimosis and paraphimosis, occur- 
ring with stenosis of the preputial aperture, or with a long, 
lax, and redundant foreskin. Phagedama is also a formidable 
complication, whether of sloughing or serpiginous tendency, 
the lesion in each case losing its chancrous characteristics. It is 
evident also that the disease may coexist with others of a dif- 
ferent character. Thus a single point may be simultaneously 
inoculated with chancroidal and syphilitic virus; the former, 
without an incubative peri< d, followed rapidly by a pustular or 



CHANCROID. 485 

ulcerative lesion ; the latter, after its incubation is complete, 
producing the characteristic symptoms of an initial sclerosis. 
Chancroids mny also be found coexisting with secondary and 
tertiary syphilitic lesions of the genitals, with vegetations, with 
blennorrhagic discharges and balanitis, with pediculi of the 
pubis, and with herpes progenitalis. Patients of the class exhib- 
iting these lesions, not infrequently present themselves at public 
dispensaries witli three or more of these concurrent disorders. 

One of the most serious complications of the chancroid is its 
association with a specific lymphangitis, peri-adenitis or aden- 
opathy. In such case, the lymphatic trunks connected with the 
lesion become inflamed, indurated, and irregularly corded, with 
the overlying integument often cedematous, reddened, and pain- 
ful. The chancrous process in these vessels rarely terminates 
by suppuration. The bubo of chancroid is more common, and 
may be either a sympathetic adenopathy, resulting from the 
severity of the process at the site of the lesion, or virulent, and 
due to the transmission of an inoculable pus to one or more of 
the glands in near connection with the sourpe of the trouble. 
These gland complications may coexist in one person, in men 
more often than in women, and in about one of each four or 
five cases presented to observation. When inoculable pus has 
been formed in a neighboring gland, the latter is at once con- 
verted into the seat of an abscess, the pus of which, whether 
evacuated spontaneously or by the knife of the surgeon, speedily 
inoculates the lips of the wound through which exit has been ob- 
tained. The wound and contiguous abscess cavity then form a 
large chancroidal ulcer, usually inguinal in situation, as the 
glands in this locality are nearest the most frequent seat of the 
lesion. Such an inguinal ulcer discharges a greenish-yellow pus, 
often commingled with blood ; its borders are undermined, thin, 
livid or purplish, and ragged; its floor is irregular, sloughy, and 
often covered by nodules representing the debris of glandular 
structure; from it depart sinuses traversing the tissues in the 
vicinity, often downward to the thigh, occasionally upward 
over the belly. When occurring in strumous and cachectic sub- 
jects, or when long neglected or mismanaged, the resulting dis- 
order is one of the most serious character, and may surpass in 
duration and severity certain of the varieties of lupus and epi- 
thelioma. I had lately under my charge a male patient, the 
skin of whose right thigh, from the groin to the knee, was com- 
pletely riddled by sinuses resulting from a chancroidal bubo 
which had occurred several years before. Two years ago, I was 
called in consultation to visit a woman in wretched health with 
an indolent ulcerative lesion of this sort in the right groin, 
which had lasted for five years. Despairing of relief, and before a 
change of treatment could be instituted, she hanged herself by 
the neck till she was dead. 

Facts of this sort have an important bearing. It is true that 



486 DISEASES OF THE S K I .V . 

syphilis is a constitutional disease, and usually occurs but once 
iu a lifetime. Ir is equally true that the chancroid is the evi- 
dence of a local and non-systemic disorder, producing constitu- 
tional effects only as may all other local affections of chronic 
course and severe grade. But it is a grievous blunder to sup- 
pose for these reasons, that the latter is the milder of the two 
maladies. Many of its consequences are very much more severe, 
and some of them even more malignant, than the average of 
syphilitic explosions, and even, as indicated above, worse than 
some forms of other diseases usually counted as malignant. It 
seems to me that greater attention should be generally directed 
to the truth respecting the comparative gravity of the two dis- 
eases, as there is widespread ignorance of the real fact. 

Chancroid is to he distinguished from syphilitic chancre, but 
no skill, however great, and no experience, however wide, will 
enable the diagnostician, even when typical chancroid is present, 
to assert that syphilis will not follow, until the longest incuba- 
tive period of the initial sclerosis of the last-named disease has 
elapsed without production of suspicious symptoms. The rule 
which necessarily follows is imperative, and, being too frequently 
ignored, a great deal of bitter disappointment on the part of the 
infected individual, and of keen mortification on the part of the 
physician, has naturally resulted. Xo patient suffering from 

A CHANCROID CAN BE SAFELY PROMISED IMMUNITY AGAINST SYPHILIS, 
TILL TWO MONTHS AND A HALF HAVE ELAPSED SINCE THE DATE OF 

last exposure. Suhject to this essential reserve, the diagnosis 
rests upon the pustular, ulcerative, and discharging features of 
the chancroid, its failure to indurate at the base, its auto-inocu- 
lability, its appearance without previous incubation, its more 
formidable localized expression of disease, and the character- 
istics of the accompanying adenopathy. The short-lived, super- 
ficial vesicles of herpes progenitalis, often accompanied by ting- 
ling an.d painful sensations, with sequela? in the form of equally 
superficial, epidermal excoriations, are not to be confounded 
with chancroids; and yet it must he remembered that these 
lesions may also precede or accompany any form of venereal dis- 
order. Chancroids are also to be distinguished from secondary 
and tertiary lesions of the genitals, and from non-syphilitic 
vegetations and molluscum epitheliale of the same region. 

The pathology of the chancroid, though illustrated by the re- 
searches of Biesiadecki, Auspitz, and Unna, is yet not under- 
stood to an extent that will explain its specific character. Ana- 
tomically, there is disclosed by the microscope a uniform, dense 
infiltration of the corium with elements which undoubtedly 
represent inflammatory metamorphosis of the connective tissue 
of the derma; degenerative changes where the ulceration has 
proceeded superficially ; enlargement of vessels from thickening 
of their walls, often with diminished lumen; and relatively in- 
tact rete and corium at the lateral borders of the ulcer. This 



CHANCROID. 487 

fully confirms the inferences suggested by a clinical study of the 
disease. Many roundish, circumscribed, clean-cut uicers with 
purulent floors occur upon the skin, which bear no relation to 
the chancroid disease. It is the history and career of the latter, 
which stamp it with an individuality of its own. It is not the 
form and appearance of its pus elements, but their power and 
potency, which make them singular. 

The treatment of chancroids is by destructive cauterization, 
with nitric or sulphuric acids. Keyes recommends a previous 
application of pure carbolic acid, in order to benumb the part 
and render the subsequent application less painful. If employed 
at all, the latter should be carefully wiped from the sore before 
the subsequent cauterization, as the two acids will explode if 
suddenly united. As the slough separates, the ulcer may be 
dressed in accordance with the general principles governing the 
treatment of simple granulating wounds. Yinous, carbolated, 
and opiated lotions, soothing powders of iodoform, calomel, bis- 
muth and starch, simple unguents and the interposition of a 
small pledget of borated cotton between all affected and sound 
tissues, these in most cases suffice to insure relief. Pencillings 
with the nitrate of silver, though ineffective for purposes of 
cauterization, often answer a good purpose in hastening repair. 
The prepuce may require division or circumcision. 

Phimosis and paraphimosis, when complicating chancroids, 
require the surgical treatment appropriate for the relief of those 
conditions; and the same may be said of phagedena. In severe 
cases of the latter, the Vienna method of continuous immersion 
in water of a uniform temperature of about 98° F., will be found 
exceedingly valuable. For the accompanying adenopathy in 
chancroid disease, before suppuration has occurred, rest is essen- 
tial, with laxatives internally and gentle local compression. 
When there is great heat and tenderness, a few leeches may be 
applied. After pus has formed, it may be evacuated with the 
aspirator needle, or by a free incision in the long axis of the 
swelling. The resulting ulcer is to be dressed and treated as a 
large chancroid. Constitutional treatment by iron, quinine, 
cod-liver oil, and the employment of a generous diet with milk, 
malt liquors, or wines, is often required in broken-down and 
debilitated patients. 

The prognosis, in uncomplicated cases, is generally favorable. 
The scar left by a suppurating gland in the groin is indelible, 
but becomes less and less conspicuous with years. Sloughing 
and gangrenous sores usually leave deforming cicatrices, espe- 
cially when occurring at the apex of the glans, to which they 
are apt to give a peculiarly truncated shape. A just reserve 
should be made in all cases complicated with syphilis or exten- 
sive fistulous sinuses; the latter, as described above, often per- 
sisting for years. 



483 DISEASES OF THE SKIN. 

Carcinoma. 

Deriv. Gr. xaixivoc, cancer. 

Carcinoma of the skin, is a term employed in the designation of the several 
forms of malignanl tumors which are in part constituted of epithelial new 
growth, either occurring primarily in the cutaneous tissues, or appearing 
there after the involvement of other organs. 

The term cancer, has been both looaely and definitely em- 
ployed in the designation of malignant cutaneous tumors. 
Every cancer of the skin is, according to Heitzinann, necessarily 
both alveolar and epitheliomatous in structure; while Kaposi 
distinctly recognizes Forma of cancer which are not epithelial. 
In these pages, for the sake of retaining a convenient clinical 
distinction, the term carcinoma, or cancer, is used generically 
to include epithelial, fihrous, and melanotic neoplasms. It will 
be understood, however, that in the structure of all of these 
new-formed groups epithelium plays an important part. 

Epithelioma (Epithelial Cancer). 

Three varieties of epithelioma are recognized, — the superfi- 
cial, the deep, and the papillary. 

Superficial Epithelioma is usually first displayed upon the 
sound skin in the form of one or several, pin-head sized papules, 
flat infiltrations, or nodosities of a dull yellowish, reddish, gray- 
ish, or dirty wax-like hue. The growth may also have its origin 
in previously existing lesions of the skin, which are both nume- 
rous and different from each other. Among the latter may be 
named, fissures and excoriations (especially those long teased 
by caustic applications), warts, nrevi, acneiform and molluscoid 
lesions; and the dry or greasy epidermal scales often seen at the 
orifices of the sebaceous glands in the faces of the aged. The out- 
line of the newly developed growth asa consequence varies, being 
roundish, linear, or irregular. As a result of accident or trauma- 
tism (especially scratching and picking, which the history of a 
large proportion of all cases includes), a superficial excoriation 
forms, which may be covered with a sero-sanguineous crust, by the 
desiccation of its scanty and ichorous secretion. In the progress 
of its development, it is often noticed that new foci of disease 
appear in the immediate vicinity of the first, represented by 
sub-epidermic, indurated nodules, or "superficial pearls" resem- 
bling milia, whitish and lustrous, with marked tendency to vas- 
cularization, exfoliation, and superficial ulceration. 

The result is the ultimate formation of an ulcer, called also 
the rodent ULCER, whose characteristics are marked. These are, 
a roundish, fissured, or slightly angular contour; and a reddish 
or reddish-brown, irregular, granulating, and m ami Hated floor, 
covered with a thin, translucent, viscid serum, which, in drying, 



CARCINOMA. 489 

suggests the effect of a varnish over the part. The edges of the 
ulcer are clean-cut, indurated, usually well attached ; and, 
seeu in horizontal profile, irregularly indented. The symp- 
toms are slight at first; the lymphatic ganglia and general 
health being unimpaired. Its site of election is the face, par- 
ticularly the eyelids, nose, temples, and lips, though the geni- 
talia, hands, and feet may be affected. Of two hundred and 
fifty cases collated by Heurtaux, in one hundred and ninety the 
face was attacked. 

The subsequent course of the lesion varies, its evolution being 
generally slow and accomplished in years. Sometimes having 
attained a maximum of size, an ulcer, if unmolested, long per- 
sists without appreciable change. In other cases, the base cica- 
trizes and the epithelioma completely exfoliates, leaving an 
outlying linear ulceration which may persist or spread. In } r et 
other cases, after a persistence of ten to twenty years, the ulcer 
may spontaneously close and the disease be at an end. Finally, 
any one of the destructive and malignant cancerous processes 
may be awakened, and the epithelioma be thus transformed 
from the type of the superficial to that of the deep variety of 
the disease. 

Deep or Tubercular Epithelioma. — This variety may origi- 
nate in the manner already described, or may be from the first 
characterized by its specific features. It commonly begins by the 
formation of roundish, very firm, pea-sized nodosities closely set 
together, deeply in the skin and subcutaneous connective tissue, 
or thus siluated and well-projected from the surface. In the 
course of months and years these develop to form a nut- or even 
small egg-sized tumor, roundish, dark reddish in color, and del- 
icately vascular on its surface. This may be a deep flattish or 
globoid development within the skin; or a well defined tumor 
attached to it; or (and this is a common form) a dense, thick, 
flattened plaque, one inch or more in diameter; its walls steeply 
descending to the sound skin on either hand or moderately 
everted; its centre depressed by atrophic changes; its surface 
shining, waxy, pinkish or red, with ramifying capillaries. "Sat- 
ellites" may form in its vicinity. 

Degeneration of these forms produces in the course of time 
an ulcer either quite like that described above, or one which 
deeply and destructively encroaches upon the tissues beneath. 
In advanced cases, the latter is irregular in contour, with a clean 
cut indurated lip; eroded and "gouged," hemorrhagic and gran- 
ulating floor; thin, viscid secretion which is purulent at times 
when the resulting destruction is rapidly accomplished ; and a 
deep attached base which may be perforated by a crateriform 
excoriation extending down to or through muscles, faseiee, car- 
tilage, and bone. The lymphatic ganglia become simultaneously 
involved, and a general cachectic condition fully established. 



490 DISEASES OF THE SKIN. 

Death may ensue from marasmus, exhaustion, or hemorrhage, 
in the course of several months or from one to three years. 

Papillary Epithelioma. — The cancer in this variety assumes 
the form of a malignant papilloma. In these cases,a pedunculated 
or Bessile, narrow or broad based, smooth -capped, <>r spongy and 
verrucous vegetation is attached to the skin upon which it forms. 

It may be originally as sum]] as a pea, hut usually increases con- 
siderably in volume, being not rarely pigeon's and turkey's egg- 
si /.e 1. The Rurfaee is either dry. reddish -yellow, smooth and 
lustrous; exfoliating, and Becreting an offensively smelling san- 
guineous or translucent fluid ; or moist, granulating, filamentous 
and intermingled with hairs, as when it occurs upon the bearded 
cheek. Degeneration occurs later, fissures forming Hrst; subse- 
quently superficial; and finally deep ulcers which ultimately 
assume all the features of those described above. 

These three varieties or types of epithelioma may coexist in 
different portions of the same integument ; or the one may 
develop from the other, a malignant papillary growth springing 
from a superficial or deep cancerous infiltration. Familial- exam- 
ples of the disease are seen upon the lids and contiguous portions 
of the nose; the cheek and the lower lid. the latter heing often 
drawn into ectropion by a cicatriform bridle or band; the nose 
or lip and adjacent mucous or osseous tissue; and the glans and 
prepuce where the vegetating forms are of more frequent occur- 
rence. The vast destruction wrought by the widest develop- 
ment and consequent degeneration of epithelioma, is sufficiently 
recorded in the annals both of medicine and surgery. I was 
lately consulted in the case of a woman sixty-four years of age, 
in the centre of whose face an ulcerating epithelioma had left, a 
wide chasm after destroying three-fourths of the nose and upper 
lip, the hard palate with all the upper teeth and the antrum. 
The bones at the base of the skull were exposed.' The case 
illustrated well the occasional remarkable tolerance by the sys- 
tem of the profound est encroachments of epithelioma. She was 
then digesting and assimilating food with fair profit, and suf- 
fered chiefly from pain. She did not die till several mouths had 
elapsed, and then only as the result of hemorrhage from an 
ulcerative opening into one of the large arteries. 

Etiology. — The essential causes of cancer are unknown, though 
there can be no question but that mechanical, chemical, and 
other local irritations are often the immediate excitants of its 
pathological processes. In this way the excoriations, warts, 
nrevi, and other lesions named above, though not in themselves 
cancerous, may become the original sites of the disease. In this 
way too the irritation produced upon the lip of the smoker by 
his pipe or tobacco; the local disorder about the inner can thus 
of the eye resulting from occlusion of the lachrymal ducts; the 
frequent teasing by caustic or other substances, of the wart on 



CARCINOMA 



491 



an old man's hand ; and other agencies disturbing the balance 
between waste and repair, aided at times by senile atrophic 
changes, may result in the development of an epithelioma. The 
possibility of the transmission of cancer by heredity has almost 
ceased to obtain credence in the light of modern pathology. 
The disease is eminently one of advanced years, being most 
frequent after the fortieth year, and a pathological curiosity in 
childhood. Kaposi reports one case at the tenth year. Only 
about thirty per cent, of all cases occur in women, a fact possi- 
bly explained by the relative in frequency of the action of local 
irritants in those who are not subjected to the exposure incidental 
to the trades and severe occupations of life. In favor of the 
local origin of all epitheliomata, is the clinical fact of the excel- 
lent general health of most patients in the earliest sta^e of the 
malady; while those affected with syphilis and tuberculosis are 
usually exempt. 

Pathology. — The histological forms of epithelioma are well clas- 
sified by Vidal, 1 as follows: 1. The interpapillary form, in which 
cylindrical or peg-like epidermal prolongations flattened at the 
periphery, penetrate downward, often in parallel columns, be- 

Fig. 51. 




Epithelioma, vertical section, a, d, cones of the rete projecting downward ; between these are 
seen atrophied papillse 6; at e, d, and other points, are "nests" of epithelium; c, atrophied 
stratum corneum. (After Kaposi.) 

tween the papilla? of the corium, and are occasionally connected 
below by a species of anastomosis. Here, at times, onion-like 
"globes," "nests," or clusters of concentrically arranged epithe- 
lial masses are to be recognized, the centre, as Heitzmann re- 
marks, being often occupied by epithelium in a state of fatty 
degeneration. In this way the derma and subcutaneous tissue 
may be, after previous vascularization, completely invaded. 2. 
The lobulate form, in which the epidermic globes are in pro- 
nounced excess, forming distinctlj- defined masses invading the 
connective tissue. Here the multiplication of the elements is 



1 Gazette des H6pitaux, Nos. 113 and 114, 1879. 



402 DISEASES OF THE SKIN. 

nbundant, thus diminishing or occluding the lumen of the vas- 
enlar elements, ami leading to necrobiosis and ulceration. 3. 
The tabular form, cylindroma of Billroth, the adinome sudori* 

pare, of Verneuil. In tins, tubes like sweat duets with a calibre, 
penetrate the meshes of the connective tissue, often intermingled 
with epidermic globes. It is largely this form of the di- 
which Tilbury Fox and T. Colcott Fox 1 have recognized as ori- 
ginating from the external root sheath of the hair follicle. 4. 
The pearly form, which Heitzmann has demonstrated to result 
from fatty degeneration of the epithelium in the centre of a 
" globe" or " nest."' 

With regard to the secondary structural metamorphoses of 
epithelioma, these are described by Heitzmann as due to fatty 
degeneration of the epithelium, which process may result in its 
calcification. Waxy degeneration of both epithelium and con- 
nective tissue, produces the appearance of shining homogeneous 
masses within the tumor, which are characterized by a note- 
worthy indifference to the action of chemical reagents. Colloid 
and adenoid metamorphoses follow the breaking apart of already 
formed cancer epithelium, into medullary elements from which 
myxomatous tissue arises. Cystic cancer is a higher develop- 
ment of the colloid form, where the myxomatous tissue in the 
alveoli liquefies. The papillary forms are exuberant growths 
of circumscribed portions of the tumor toward and beyond the 
surface. 

Briefly, every column, "nest," "globe," or tubular prolonga- 
tion within the skin, containing within itself an irregular ad- 
mixture of epithelium and connective tissue, is a cancer, or epi- 
thelioma, whose gravity seems to be proportioned to the relative 
development of the contained epithelium. As to the origin of 
the latter, Heitzmann is in accord with Virchow in affirming 
the fact of its production from connective tissue. The medul- 
lary elements into which connective tissue is transformed as the 
result of an inflammatory infiltration, have been traced in the 
process of metamorphosis into cancer epithelium. Once fully- 
developed, the neighboring lymphatics are invaded, and second- 
ary involvement of the viscera may follow. These minute epi- 
thelial [(articles of the neoplasm are swept into the lymph gan- 
glia, thence through the lymph- to the bloodvessels; where 
finally, lodged in capillaries with a narrow lumen, they produce 
embolism. 

The malignant forms of cancer may undergo changes by which 
they are transformed into myeloma (sarcoma, of Virchow). In 
these, the epitbelia become gradually indistinguishable as such, 
in consequence of a species of liquefaction by which they are 
converted into medullary elements. 

1 Trans, of the London Path. Soc, 1879. 



CARCINOMA. 493 

Diagnosis. — Epithelioma is to be distinguished from lupus 
vulgaris approximately, by the age of the patient, the latter 
disease rarely appearing after the thirty-fifth year where there 
is not a scar or history of its earlier existence. Lupus is, at an 
earlier period of its career, more diffuse than epithelioma; its 
elementary lesions are more distinctly groups of individuals 
than a homogeneous aggregation; its ulcers are more often bor- 
dered by outlying non-ulcerative papules, furnish a more puri- 
form discharge, and, most distinctive of all, are never walled 
about by the firm, densely indurated, often everted lip of the 
epitheliomatous ulcer, opening out often to a sound peripheral 
integument. The peculiar and often characteristic odor of the 
cancer discharge, is absent in lupus. 

From syphilis, epithelioma is to be distinguished: first, by 
the age of the patient, syphilis being decidedly a disease of early 
and middle life; second, by the far greater relative rapidity of 
the syphilitic process, exception being always made of tertiary 
gummatous ulcers upon the lower extremities, persisting for 
years when there is both lack of internal treatment and local 
support; third, by the history of the disease in each particular 
case; and fourth, by the characteristic syphilitic features always 
present in infected individuals, including multiplicity of lesions, 
typical cicatrices, contour of ulcers (that of epithelioma is rarely 
either reniform, horse-shoe shaped, or crescentic), character of 
discharge, and general absence of pain. A very important point 
to note is a marked tendency to partial cicatrization in old 
syphilitic ulcers, partly due to the exhaustion of the infective 
poison, partly to the influence of the insufficient but yet modify- 
ing treatment so common in this country. This is exceedingly 
rare in epithelioma, the latter being often, the former rarely, a 
malignant disease. 

Epithelioma of the genitals is not to be confounded with 
chancre, or syphilitic tubercles of that region. The peculiari- 
ties of the consequent adenopathy in each case ; the lancinating 
pains of the cancer;, its much more prolonged duration; and 
occurrence in an aged subject, with the general history of the 
case, will usually point to the truth. 

Myeloma (sarcoma) is characterized by, its far more rapid 
development, tumors often attaining their maximum of devel- 
opment in the course of a few months; its occurrence by predi- 
lection in earlier life; its inaptitude for ulcerative degeneration ; 
and its marked tendency to multiplication in contiguous or dis- 
tant portions of the body. 

The warts, neevi, excoriations, and seborrhceic lesions, from 
which epitheliomata often take their origin, cannot be deter- 
mined as having such a tendency before the cancer has attained 
some development. Every such persistent and long irritated 
lesion on the person of a male subject of advanced years, should 
be regarded witli a degree of suspicion. 



-±04 DISEASES OF THE SKIN*. 

Treatment. — The treatment of epithelioma is by excision, era- 
sion, or destruction of the growth. The first is performed by 
Burgieal ablation with the bistoury, after which one of the 
plastic operations may be required for eitber the complete cov- 
ering of the wound, or the relief of the resulting deformity. 
The second is applicable only to the less formidable orowths, 
and is performed by the aid of the dermal curette. 

Destruction of cancerous tumors of the skin is usually per- 
formed by the aid of caustics, of which caustic potas.sa, in stick 
or solution, is. perhaps, the most valuable, as its destructive 
action may be controlled by the topical employment of acids, 
and is followed by less pain than some other chemical agents. 
Other caustic substances employed for a similar purpose, are 
chloride of zinc, Vienna paste, nitrate of silver, arsenical paste, 
and pyrogallic acid. The latter is recommended highly by 
Kaposi, not only because its application is unproductive of 
pain, hut also because it does not attack sound tissue. It is 
used in an ointment of ten per cent, strength. All such pastes 
and ointments should be spread upon cloths, and applied for 
from three to six days. Opiates may be required, in the case of 
several of these agents, to relieve the consequent pain. 

Among the formulae used for caustic purposes are the follow- 
ing : — 

K. Creasoti § ss ; 16 

Acid, arsenios. gi*. iv; 266 

Opiip- gr. ij; 138 M. 

" For employment upon circumscribed surfaces." (Kaposi.) 

Cosme's paste, as modified by Hebra, is prepared as follows: — 

IJ. Acid, arseuios. gr. vj ; !40 

Hydrarg. sulplmret. rub. 3ss ; 2 

Unguent, aq. ros. gss; 16 M. 

Sig. "Arsenical paste." 

The method of its application is as follows: The paste is 
spread over a thin sheet of lint to the thickness of a knife- 
blade, and the lint then cut to a shape and size corresponding 
with that of the tumor or ulcer to be destroyed. After its close 
apposition with the surface to he attacked, it should he covered 
with gutta percha, or other impermeable tissue, and a compress 
laid over the whole. The dressing is removed, the parts washed 
clean, and the same application renewed in twenty-four hours. 
By the third or fourth day, the destruction of the cancerous 
growth is usually complete, and the parts are ready for an 
emollient poultice, which should be applied for the three or 
four days, during which the separation of the sloughs occurs. 
The simple ulcer left, is to be treated on general principles. 
The danger of arsenical poisoning is here reduced to a mini- 
mum ; the treatment being very effectual where patients con- 
sent to the delay as to time, and the very severe pain which it 
occasions. It has been used by me with satisfactory results, 



CARCINOMA. 495 

and is highly praised by Atkinson 1 in an admirable lecture on 
epithelioma, delivered by him in the University of Maryland. 

The thermo- and galvano-cautery also may be often advan- 
tageously used for the destruction of the growths. I have used 
the former by preference in many cases, occasionally without, 
often with return of the neoplasm. Its advantages are, the 
transitory character of the induced pain ; the coal-like dressing 
left upon the attacked surface; and the elegance of the resulting 
scar. Both measures find their highest value when employed 
after effectual excision or erasion. 

Whatever method be employed, thoroughness is essential in 
attacking all portions of the new growth ; and it is well to en- 
croach somewhat upon the unaffected contiguous structure. 
The subsequent dressings should be made with simple or ear- 
bolated unguents, to which one of the stilts of morphia may be 
added in case of continuous pain. The eschar usually separates 
in the course of a few days, leaving a simple granulating wound, 
which may cicatrize soundly, and the epithelioma be thus radi- 
cally relieved. In other cases, the disease reappears in the ulcer 
or cicatrix; or by recurrence of cancerous nodules in the previ- 
ously sound integument. Even after these recurrences, prompt 
destruction of the new growth may be finally successful. 

But little confidence is placed upon either internal or external 
treatment, which does not look to the complete destruction of 
the neoplasm. Yet there are those who highly esteem some of 
the procedures which are less radical in their aim. It is proper 
to mention these. 

There can be no doubt whatever but that some circumscribed 
and relatively small growths disappear under the hot-water 
treatment. The sole question which then arises concerns the 
possibility of spontaneous recovery in such cases irrespective of 
the treatment pursued, since such spontaneous involution is a 
clinical fact, rare of occurrence though it be. By this method, 
the neoplasm is sponged with hot water for from fifteen to 
twenty minutes every three hours of the day, and oftener if 
possible, for three weeks in succession. The water is as hot as 
can be tolerated, and applied by the aid of a bit of sponge 
mounted on a probang. During the course of the application, 
water in a state of ebullition, is added in small quantities to 
that in which the sponge is dipped from minute to minute, 
thus keeping the temperature at the highest tolerated point. 
Immediately after each application, the part is thoroughly 
dried, and then either anointed with a bland unguent or com 
pletely covered with iodoform in powder. When such applica- 
tions are of service, the good effect will usually be noted in a 
week. The ulcer changes its aspect in color, edges, and floor; 

1 Reprint, in Chicago Med. Journ. and Exam., Aug. 1880, p. 188, from the 
Virginia Medical Monthly. 



496 DISK ASKS OF TIIK SKIX. 

and the pain, if any have existed, is greatly relieved. Granu- 
lations .if a healthy type appear, and the lips of the si. re con- 
tract. Non-ulcerated lesions slnink in volume, and otherwise 
change in feature. This system of "parboiling" has the advan- 
tage of not precluding the ultimate employment of radical 
measures. The largest epithelioma I have completely relieved la- 
this method, was of the type of the "rodent ulcer," on the temple 
of a gentleman seventy two years of age. It had the size of a 
section of a small hen's egg. The resulting cicatrization was 
satisfactory in all respects. There lias heen no return in two 
years. Needless to say the method will often fail. 

Leveque, 1 Vidal, 2 Bergeron, 3 Euthyboule, 4 and others claim 
large success in the treatment, of epithelioma by chlorate of 
potash. Locally, the part is frequently touched with a saturated 
solution of the salt in glycerine and warm wafer, after which a 
simple ointment dressing is applied. Vidal administers also the 
same drug internally in doses of a drachm and a half (6.) in 
syrup and water before meals. I am inclined to believe that 
any remedial effect obtained from such measures, should be 
attributed to the fomentations employed. 

Prognosis. — In general, it is scarcely necessary to say that the 
prognosis of cutaneous cancer is grave. The relative degree of 
gravity will, of course, be largely proportioned to the variety, 
form, size, career, and complications of the growth in each case. 
The variety in which "pearls" only form in the skin, is the most 
benign of all, as the lesions are usually isolated, and often, when 
unirritated, undergo spontaneous exfoliation. In other cases, 
the disorder for from .fifteen to twenty years seems to make no 
progress of any sort. The malignity of a cancerous growth is 
always proportioned to the quantity of epithelium contained in 
its alveoli as compared with the connective tissue present; the 
more abundant the latter,the more favorable the prognosis. Natu- 
rally, also, the deeper and the more destructive the growth, the 
fewer are the chances of ultimate recovery. Excessive pain and 
adenopathy are unfavorable symptoms in any case. Koch 5 gives 
some interesting statistics of the results of operations, at the 
Erlangen Clinic, for removal of epithelioma of the lower lip, in 
one hundred and thirty-one patients exhibiting primary lesions. 
One hundred and fifteen were for the time "cured ;" four had 
speedy relapse; and three were, at the date of writing, living 
and suffering from recurrence of the disease. The prognosis 
was thus absolutely favorable in but twenty-eight cases. 

Cancer of the Connective Tissue. 
This is rare as a primary cutaneous manifestation, but ap- 
pears generally as secondary to a cancerous involvement of 

1 Glasgow Medical Journal, 1881. 2 Loc cit. 

3 Acad, de Med., Paris, 1873. 4 These de Paris, 1877. 

B Ctblt. f. Chiiurg, 1881, No. 40. 



CARCINOMA. 497 

other organs, as of the female breast. It is termed also scir- 
rhous, hard, fibrous, or lenticular cancer. It occurs either 
upon the skin covering a breast which has been previously 
transformed into a cancerous mass, or as a cutaneous relapsing 
lesion after the extirpation of the latter. Its symptoms are 
pea- to bean-sized, densely firm, shining nodules, varying in 
color; or a more or less diffuse infiltration of the skin, of similar 
characteristic hardness, associated often with hyperaemia of a 
purplish-red shade. 

When the cancerous infiltration is widely diffused and indu- 
rated, involving at once a large portion of the integument of 
the thorax, the condition is produced which is termed by the 
French, cancer en cuirasse. This infiltration also is usually 
secondary to involvement of other organs; but, according to 
Cornil and Besnier, 1 it may first develop in the skin. Patho- 
logically, the form of carcinoma here described is also epithelio- 
matous, since its fibrous stroma always contains, in the centre 
of narrow alveoli, a relatively small number of epithelial bodies. 
It is usually slow of development, but in the end accompanied, 
as are other cancerous tumors, by adenopathy, pain, and ulcer- 
ative changes, which induce an inevitable cachexia. Like the 
other varieties also, relapse after extirpation is common, and 
the prognosis proportionately grave. 

Tuberose Carcinoma 

is a rare manifestation of the disease, occurring in the form of 
multiple, firm, peanut- or egg-sized, roundish nodules, which 
break down by ulcerative processes into deep losses of tissue. 
It is frequently accompanied or followed by cancerous involve- 
ment of other organs. It occurs chiefly upon the face, hands, 
arms, and chest, though also upon other portions of the skin of 
persons of advanced years, either as a primary or secondary 
cancerous manifestation. Guinard 2 reports the case of a cancer 
of this variety, remarkable for the small size of the existing 
nodules, which varied from that of a hempseed to a pea. They 
covered the entire thorax, back, and right arm, and had here 
and there broken down into ulcers. One of the latter was as 
large as the hand. 

Melanotic or Pigmented Carcinoma 

is that form in which both the epithelium and connective tissue 
framework of the cancer are richly supplied with bloodvessels, 
and probably, as a consequence of transudations from the latter, 
an abundant supply of pigment granules in groups and clusters. 
These growths usually begin as hempseed- to pea-sized, nu- 

1 Bulletin de la Soc. M^d. des Hop., p. 158, 1878. 

2 Union Med., Feb. 5,1881. 
32 



498 DISEASES OF THE SKIN. 

merous, soft or dense nodules, Avliicli may develop in time to 
tumors of considerable size, and are stained in various shades 
from a slate-color to a dead black, the pigment being occasionally 
displayed irregularly in Btreaks or bands over the surface of the 
growth. They occur over any portion of the surface, oftener 
upon the extremities and genitals, starting frequently from 
benign pigmentary lesions, such as nsevi and moles. I have in 
a lew instances seen the disease limited to single melanotic 
growths of this character. The cancel- is apt to develop in the 
papillary form, furnishing thus fungoid vegetations which have 
a noteworthy tendency to degenerate into ulcers. Often such 
verrucous masses are seen surrounded \>y grayish or blackish 
papules, or by a diffuse cancerous infiltration of the integument, 
exhibiting Irregular pigmentation of the surface. The disease 
is apt to appear in the viscera, in the form of disseminated can- 
cerous nodules, each highly vascular, and exhibiting in various 
degrees granules of pigment. The growth has usually a rela- 
tively rapid course and malignant career. A nut-sized melanotic 
cancer of the skin, removed from the hand of a patient in Chi- 
cago by one of my colleagues, was not followed by other mani- 
festations of the disease during the ensuing year. At the end 
of that time the patient escaped from observation. 

Myeloma Cutis (Sarcoma of the Skin). 

Deriv. Gr. |UusXo?, marrow. 
Myeloma of the skin is characterized by the occurrence, either as primary or 
secondary developments, of single, though generally multiple, pea- to egg- 
sized and larger, pigmented and non-pigmen ted, cutaneous neoplasms, having 
a marked inaptitude for ulceration, but malignant in character, recurring 
after extirpation, and usually terminating fatally with involvement of the 
viscera. 

Symptomatology. — For the term sarcoma, meaning a fleshy 
tumor, originally employed by Virchow in the designation of 
this disease, that of myeloma is here substituted as proposed by 
Heitzmann. The signification of the latter word, meaning a 
medullary tumor, justifies its employment for this purpose. To 
Ileitzmann's aide paper on tumors of the skin, 1 we are largely 
indebted for the clinical and pathological history of this rare 
disease. .Cases have been reported by Kaposi, Kobner, Tanturri, 
Billroth, and others abroad ; and, in this country, by Wiggles- 
worth, of Boston. 2 A remarkable instance of this disease has 
also heen observed by myself, a fatal result occurring rapidly 
after the development of the tumors. 3 

• Arch, of Derm.. Oct. 1880, p. 378. ■ Arch, of Derm., ii. No. 2. 

3 This patient died 'within a few months after he came under my observa- 
tion ; and the case was then regarded by me as one of multiple sarcoma of the 
skin. The death certificate was so worded. Subsequently and before the careful 
microscopical examination of sections of one of the tumors, I was led to believe 



MYELOMA CUTIS. 



499 



The disease may originate in the skin as a secondary manifesta- 
tion of visceral involvement, or may be first displayed by cuta- 
neous symptoms. These may spring from some preexisting 
lesion, or from a chronic benignant infiltration of the skin fol- 
lowing any cause; or even from a rapidly-growing epithelioma. 

The lesions are at first pea- ro bean-sized, usually multiple, 
roundish, firm, circumscribed, irregularly arranged, discrete or 
confluent tubercles, which have a characteristic whitish, reddish- 
brown, or reddish and purplish tinge. By confluence or incre- 
ment in volume, often by both, they develop into roundish, 
ovalish, or irregularly shaped tumors, having often a sausage- 
shaped contour, varying in size between the smallest and largest 
hen's eggs. They occur upon all parts of the body, more par- 
ticularly upon the palmar and plantar surfaces, the forearms, 

Fig. 52. 




The author's case of myeloma (sarcoma) cutis. (Drawn from an oil painting taken, 
at the hedside.) 

the legs, the face, and the back. Often they are in various de- 
grees pigmented, showing then purplish, brownish, or even black 
colors. They are usually painful, and may or may not be 



from several anomalous features of the disease, that it was one of acute lepra, 
and so reported it in the course of a few weeks at the meeting of the American 
Derraatological Association in 1881, reserving a more accurate diagnosis till 
the sections had been examined. The result of the latter showed that I had 
been completely in error. The case was a rare and singular one, of multiple 
cutaneous myeloma (globo-myeloma, as described below), the diagnosis by the 
microscope being fully confirmed by my friend, Dr. Heitzmann. 



500 DISEASES OF THE SKIN. 

render. They sometimes disappear, leaving atrophic or pig- 
mented depressions as relics of their career. They are said to 

ulcerate rarely. In the ease of tny patient, ulceration attacked 
some of the tumors, leaving crateritbrm excavations in their 
centres, but this was an exception to the rule, the larger number 
present preserving their shape in death. In a few, vegetations 
appeared upon the summit, smeared with a thin and very offen- 
sive secretion. 

As the disease progresses, cachexia is induced. "When the 
tumors are numerous, swelling of the limbs and (edema or" the 
face and other portions Of the body supervene, with ptosis of the 
lids where tumors may rest. At the same time febrile accesses, 
alternating with chills, diarrhoea, inappetence, and other signs 
of gastro-in test i rial impairment, become conspicuous symptoms. 
The scene is speedily closed by death. 

When the tumor is single and apparently uncomplicated by 
involvement of deeper organs, extirpation is usually followed by 
recurrence, either in the scar or vicinity, with added malignancy. 

A peculiarity occasionally noted of multiple myelomata oc- 
curring on the backs of the hands, is the relative size of the 
lesions, which may be no larger than small marbles, with infil- 
tration of the skin lying between the latter, producing thus the 
appearance of a small, well rounded, cushion, The epidermis of 
such an cedematous hand usually exfoliates in silvery-white or 
grayish scales, more or less adherent. The feet and legs may 
exhibit a similar appearance. 

In advanced cases, the odor emanating from the body of the 
patient is as fetid as that of continent variola. 

Etiology. — The causes of myeloma are unknown. As distin- 
guished from epithelioma, however, it occurs in earlier years, in 
childhood and middle, rather than in later, life. It is somewhat 
more common in males than in females. 

Pathology. — Heitzmann, reviewing Virchow's five varieties of 
sarcoma (round-cell, spin die-cell, net-cell, giant cell, and mela- 
notic sarcoma), concludes that there are but two distinct varie- 
ties of the disease, globo-myeloma (round-cell sarcoma) and spin- 
dle myeloma (spindle-cell sarcoma). 

Globo-myeloma is constituted of globular protoplasmic ele- 
ments closely packed together and separated by a very narrow 
layer of cement-substance, traversed by delicate prolongations 
of the living matter which uninterruptedly connect the elements. 
The vascular supply is scanty. There are two forms of this 
growth found in the skin: (a) Those with relatively large pro- 
toplasmic bodies and large nuclei — "large globo-myeloma ;" (b) 
Those with relatively small homogeneous lumps of living mat- 
ter — "small globo-myeloma," or " lympho-myeloma." 

Spindle myeloma is constituted of a decussating felt-work of 
spindle-shaped, nucleated, protoplasmic bodies. According to 



MYELOMA CUTIS. 501 

the relative size of the elements, the tumor is recognized as a 
large or small spindle myeloma. 

In the " alveolar sarcoma" of Billroth, there is a delicate con- 
nective tissue frame-work, containing attached globular or pyri- 
form bodies. Heitzmann has recognized this form once, in the 
skin of the left groin. 

The melanotic varieties, which are especially malignant, ex- 
hibit granules or clusters of pigment, both in the connective 
tissue and medullary elements. 

The compound varieties of the disease, myxo- and fibro- 
myeloma, are occasionally seen in the skin. The formation of 
secondary tumors is explained, according to Heitzmann, by the 
transmission of minute particles of the neoplasm to capillaries 
of a tine lumen, presumably through the bloodvessels, as the 
lymph ganglia are rarely involved. 

Diagnosis. — Having in consideration the relative rarity of this 
disorder, it must be admitted that the diagnosis is often attended 
with some difficulty. From lupus vulgaris, with which it may 
be confounded in view of the age of the patient, it may be recog- 
nized by its relative rapidity of evolution, its failure to ulcerate 
at an early stage, and. the absence of cicatrices in cases where 
there has been no operative interference. 

Syphilis is to be distinguished by its history; its multiformity ; 
its ulcerative type; and its amenability to specific treatment. 
Lepra does indeed, when occurring in its rarer and acute forms, 
suggest the multiple myelomata of the face. But the presence or 
history of hypersesthetie or anaesthetic symptoms, of bullous or 
macular lesions; and the absence of deforming mutilations in 
advanced periods, will usually point to the nature of the disease. 
The tubercles of lepra are smaller than the tumors of myeloma ; 
more bronzed and less fleshy in color; and of far less general 
distribution than in several cases of myeloma on record. 

Treatment. — Thus far the treatment of myeloma has been 
singularly ineffectual. The comfort of the patient is to be se- 
cured by all measures, including anodynes in an advanced stage 
of the disease; and his strength should be supported by a gen- 
erous diet and tonic regimen. When the disease is generalized, 
tepid, baths are productive of great comfort, and the use of car- 
bolic acid, or some similar agent, is indicated by the fetor arising 
from the person. The body should be anointed with a bland 
unguent after each bath. When the lesions are single or few, it 
is doubtful whether extirpation should be practised. 

Prognosis. — The future of the myelomatons patient is indeed 
dark. A fatal result may be anticipated in a period varying 
between a few months to five years. The pigmentary tumors 
usually prove fatal in the course of two years. Immediate 
gravity attaches to rapid development of the lesions and visceral 
implication. 



502 DISEASES OF THE SKIN. 



Inflammatory Fungoid Neoplasm. 

Under this title, Bebra, Kaposi, Geber, Dull ring, 1 and Piffard* 
describe a disease bearing a close resemblance to myeloma. Tlie 
lesions are coin to palm-sized, roundish or ovalish, flattish 
or elevated infiltrations, superficial or deep, smooth, desqua- 
mating or crusted ; and, in different stages, yellowish, pinkish, 
reddish, or purplish in color. Some of these disappear after a 
time by spontaneous involution ; others spread by extension 
for weeks. After desquamation from any infiltrated patch, a 
viscid serum is exuded. In some, there is central involution, 
leaving there a depressed, pigmented, macular lesion, surrounded 
by a brownish-red ring. Other lesions described, often seen at 
one and the same time, are fungous, verrucous, or lobulated, 
pea- to egg-sized tubercles or tumors, irregular, secreting, soft 
or firm in texture, roundish or ovalish, and colored in various 
shades of light and deep red and purple. The lesions are asym- 
metrical in distribution ; variable as to the subjective sensations 
they awaken ; and develop suddenly, or require weeks or months 
for their evolution. They may terminate in sauious ulceration. 
They occur upon all regions of the body. 

Anatomically, the new growth is seen to be composed of 
closely packed, small, round, shining, finely or coarsely granular 
elements, in aggregated masses or columns invading both the 
derma and subcutaneous tissue. 

Heitzmanu 3 regards this disease as a compound neoplasm, or 
fibro- myeloma ; and Kaposi classifies it with the malignant 
sarcomata of the skin. Sooner or later the disease terminates 
fatally in all cases. The mycosis fort goid.e, of Bazin, undoubtedly 
belongs to the same category ; and Duhring is disposed to con- 
sider as of similar pathological significance, the growths de- 
scribed by Kobner as "multiple, fungoid, papillomatous tumors 
of the skin;'' that reported by Tilbury Fox as ''fibroma fiin- 
goides," the " lymphadenie cutanee" of Grillot and Demange, and 
the " ulcerative scrofuloderm" of Dr. Van liarlingen, of Phila- 
delphia, which has been made by him the subject of a valuable 
paper. 4 

An explanation of the diversity of names suggested for these 
various manifestations of a malignant disease, may be found in 
their rarity, only about twenty-five cases of these types of cuta- 
neous myeloma having been recorded abroad, and somewhat 
less than half that number in this country. The entire subject 
is one with respect to which a wider knowledge is in course of 
acquisition by observation and study. 

1 Arch, of Derm., Jan. 1879, and Jan. 1S80, with two portraits. 

2 Reported by Duhring. 

3 Loc. cit. ' * Arch, of Derm., April, 1879. 



TINEA FAVOSA. 503 



Class X.— OF THE SKIN AND ITS APPENDAGES, ALL PARA.SITIC. 

The cutaneous disorders of this class, possess many features in 
common with those already described. In them, as in others, 
are observed the hypereemic and exudative processes which 
result iu surface lesions of similar type and career. They differ, 
however, from other affections of the integument, in that they 
are all induced by parasites of either vegetable or animal 
origin ; and are, as a consequence, commonly characterized by 
certain special features. They involve the skin and its appen- 
dages, their symptoms being at times displayed chiefly in the 
integument proper, and at others in one or more of the cuta- 
neous appendages, according to the mode of propagation and 
attack, peculiar in each case to the parasite present. They are 
all in different degrees contagious; and being induced by local 
and tangible causes, are usually readily relieved by external 
treatment. Their importance in cutaneous medicine rests not 
only upon the facts named above, but also upon the too gen- 
eral misconception regarding their nature, since there are many 
patients treated by internal remedies ingested vainly for long 
periods of time, who are yet suffering from parasitic disorders 
often remediable by very simple local measures. ^ 

It should not be forgotten, however, that, distinct though 
these maladies be in an etiological sense, they are j^et practically 
often commingled with others. Thus an eczematous scalp in a 
child may by accident become the habitat of lice ; and the 
eczema induced originally by the acarus scabiei may long per- 
sist after the destruction of the parasite. 

The term tinea, derived from a Latin word meaning a moth 
or worm, has by common consent been adopted as a generic 
designation of all the cutaneous disorders induced by the pres- 
ence of vegetable organisms. 

1. Of Vegetable Origin. 

Tinea Favosa. 

Deriv. Lat. favtis, a honeycomb. 

Tinea favosa is a contagious disease of the scalp, and less frequently of other 
portions of the surface of the body, chai'acterized by pea- to coin-sized, sul- 
phur-yellow and umbilicated crusts commonly traversed by hairs, and pro- 
duced by the invasion of a vegetable organism, the achorion Schonleinii. 

Symptomatology. — Favus affects chiefly the scalp, but also oc- 
curs upon the so-called non-hairy portions of the skin and the nails. 
In the former situation, it is usually first recognized by the de- 
velopment of minute, sub-epidermic, yellowish puucta, visible 



504 DISEASES OF THE SKIX. 

through the translucent stratum corneum at the site of implanta- 
tion of the hairs. Puncture with a needle usually gives exit to 
a puriform matter. In the course of a fortnight or more, these 
develop into pea-sized and somewhat larger, friable, circular, and 
elevated crusts, having the yellowish tinge of* the lemon or sul- 
phur, and a coucavo convex shape, with the free concave face of 
the disk exposed. At the centre of the umbilication thus pre- 
sented to the eye. one or several hairs usually make exit to the 
BUrfaee. The interior surface of this disk rests upon the scalp, 
which is either moist and deprived over a circumscribed area 
of its epidermis, or is smooth, dry, reddened, and tender. When 
the crust is removed by traction upon the hairs or otherwise, 
a minute cup shaped depression is left at the point where the 
lowest level of the favus crust was in intimate connection with 
the epidermis. 

The subsequent features of the crust, the hairs and the scalp, 
are subject to some variation. The first may acquire a brownish 
or greenish tinge by admixture with dirt or dried pus; or may, 
by gradual desiccation, exchange its yellowish hue for the dirty 
whitish shade of old mortar, a substance which it then resembles 
in its dryness and friability. The hairs, invaded both in sheath 
and shaft, may lose their lustre; become fragile: appear as frac- 
tured relics of longer filaments; be readily extracted from their 
follicles; and be finally shed, leaving behind, hair-sacs destined to 
fall into atrophy, and incapable of reproducing a pilary growth. 
The scalp may be first the seat of an extensive hyperasmia or 
exudation going on to the formation of pus, when the organism 
is a source of acute irritation in consequence of its active de- 
velopment. Later, when its destructive work may be said to 
have been accomplished, the scalp surface is bald, irregularly 
atrophied, or disfigured with minute cicatrices, while here and 
there remain tufts of hair which have survived the attack. 

The lesions may be discrete or continent, and vary in either 
case. Occasionally but a few small and ill-developed crusts form 
upon the surface. I have but once seen the entire scalp covered 
with a confluent favus crust. The disease is usually chronic in 
its course. Untreated, it, may undergo spontaneous involution 
after total destruction of all hairs and production of general fol- 
licular atrophy, but this is rare. It may last for fifteen or twenty 
years, and even longer. It is often accompanied by adenopathy. 

The disease usually awakens a noteworthy degree of itching; 
and, as a result, it is not rare to find the favus crusts torn and 
broken by the comb or the nails. 

The yellowish disks of the disease occur also in typical devel- 
opment, though more rarely, upon the surface of the face (in- 
cluding the bearded cheeks, lips, and chin), and upon the trunk 
and extremities. Dr. Geo. Henry Fox, of New York, has a pho- 
tograph of a patient's knee which is covered on its extensor 
aspect with favus crusts. 



TINEA FAVOSA. 505 

When the nails are invaded, light or deep yellowish, circum- 
scribed snots become visible through the nail structure, and by 
the extension of these, in consequence of the growth of the para- 
site, the nail tissue may he thickened, irregularly split, laminated, 
separated from its matrix, or atrophied. The complication is 
rare, and supposed to be due to the transfer of the organism 
from the scalp to the hands in the act of scratching. When it 
exists, the epidermis fringing the nail, is usually also involved. 

The odor of fully developed favus is so characteristic that by 
it alone a diagnosis has been established. It is usually com- 
pared to the odor of mice ; also to that of the urine of cats. It 
should not be confounded with the peculiarly disgusting odor 
of many neglected scalps affected, with lice or covered, with 
pustules and filth. The disease not infrequently coexists with 
other cutaneous, parasitic and non-parasitic diseases: as, for ex- 
ample, seborrhcea, eczema, and tinea tonsurans. 

Etiology. — Favus is always produced by the presence and 
development of the vegetable organism which is named after its 
discoverer, the achorion Schonleinii. It is a contagious disease, 
simply because the parasite which produces it, is capable of trans- 
mission from man to man, as also from animals to man, and 
vice versa. It shares with other diseases originating from vege- 
table parasites, the peculiarity of attacking certain individuals 
specially predisposed to the invasion, either by physical peculiari- 
ties of organization, or accidental and fortuitous circumstances. 
It is most common from infancy to the thirtieth year of life. 
It is rare in the United States, Austria, and England ; and more 
common in France, Scotland, and Poland. It is said by Bergeron 1 
to be a disease of the country; while tinea trichopbytina pre- 
vails in the cities. 

Evidences of contagion are exhibited in those cases where 
several members of the same household are affected with the 
disease ; but in other cases the absence of a history of contagion 
after exposure, indicates the relative difficulty experienced in 
propagating the contagious element in the case of favus. Thus 
one individual, exposed among a dozen who are diseased, will 
fail to exhibit any favus crusts; and the latter by no means form 
in all situations of the same body where the fungus can be dis- 
covered by the microscope. Aubert, 2 indeed, presents an argu- 
ment in favor of the production of the disease by traumatism, 
the resulting wounds, excoriations, etc., becoming by accident 
the seat of the disease. 

Occasionally favus occurs in special localities with such de- 
velopment among men and the inferior animals as to constitute 

1 Etude sur la Geographie et la Prophylaxis des tei^ues, Paris, 1865. 

2 Role de traumatism dans l\:tiologie de la tei<me faveuse, (Annal. de Derm, 
et de Syph., April, 1881). 



506 



DISEASES OF THE SKIN, 



an epidemic. Girard 1 reports thus the simultaneous existence 
of the disease among sixteen cows and tour children in the vil- 
Inge nf Nantoiu, in France. It is propagated also upon the 
skin of rats and mice, from which it is transmitted to man, 
often through the medium of the domesticated cat and dog. 

Pathology.— Under the microscope, the fungus is readily recog- 
nized in the root sheaths, the bulbs, and the shafts of the hairy 
filaments near the scalp. At a distance of about two inches 
from the hull) it ceases to appear in the tissue of the hair. It 
is also seen upon the free surface of the vskin. The favus crust, 
softened by the addition of a little water, or dilute liquor 
potussse, may he placed upon the slide of the microscope with- 
out other preparation for its study. Under a good one-fourth 




Achorion Schonleinii. 



sporophores. (After Coroil and Ranvier.) 



or one sixth of an inch objective, the vegetation is seen to he 
composed of intricate masses of mycelium and spores in great 
quantity. 

The former usually preponderate, and appear as narrow, flat- 
tened, ramifying, short or elongated, thread-like cells or tubes. 
These may he simple and empty, or be divided more or less regu- 
larly by transverse partition walls, transforming the longer and 
simple into shorter and compound cells. The latter often con- 
tain in their cavities, sporules clinging to either side, in which 
case the mycelial threads are termed sporophores. This is the 
vegetative part of the cryptoganious fungus ; and it develops by 
multiple subdivision into cells, which may also themselves simi- 
larly increase in number, or by the production, at the terminal 
extremities of certain of the mycelial threads, of spores or co- 
nidia. The latter are encapsulated, or strung together like the 
heads upon a necklace, and appear as round, ovalish, angular, 



! Lyon Mod., Aug. 15, 1880, p. 547. 



TINEA FAVOSA. 507 

or very irregularly contoured bodies, often provided with parti- 
tion walls like the mycelia, constituting thus compound cells. 
At the same time, an amorphous granular matter can usually be 
distinguished in the mass of the fungus. According to Duhring, 
who has made careful measurement of these elements, mycelia 
vary in width from .0023 to .0030 mm. ; and the spores, from 
.0023 to .0052 mm. 

Examination of the invaded scalp reveals, according to Unna, 1 
the presence of the fungus at the lower border of the upper 
three-fourths of the root-sheaths, where chains of conidia ap- 
pear among the histological elements. His view is, that the 
cuticle of the hair offers a relative resistance to the growth of 
the vegetation; that the latter first penetrates the stratum cor- 
neum and the follicular orifice, and then stretches, upon the one 
hand, into the cortex and medulla, through the cuticle of the 
hair; and, on the other, passes to the inner root-sheaths, the 
outer remaining always intact. In the epidermis, the fungus 
has a predilection' for the tissues between the superficial and 
deep portions of the stratum corneum, stopping as if before a 
wall, at the living protoplasmic masses of the rete. The superior 
pars* vascularis of the corium exhibits enlarged vessels sur- 
rounded by inflammatory elements. 

When the nail is involved, the parasite may be recognized in 
the debris produced bj' scraping the nail-substance; often also 
in the epidermis bordering the nail. It exhibits here the same 
microscopical features as upon the scalp, though, in consequence 
of the denser structure of the nail-substance, its vegetation is 
usually less luxuriant. 

Diagnosis. — The clinical recognition of favus is based upon the 
presence of the characteristic, yellowish, cup-shaped crusts, often 
aided by a history of contagion, and the peculiar odor emanating 
from the scalp. The secondary effects upon the hairs, hair-fol- 
licles, and skin, are also, when present, significant. Dr. White, 
of Boston, in a valuable essay on the "Vegetable Parasites, and 
the Diseases caused by their Growth upon Man," calls attention 
to the stage in which the disease is likely to be mistaken for 
ringworm. It exists before the formation of the crust, and may 
be characterized by hyperoemia, vesiculation, or papulation, often 
unnoticed beneath the hairs of the scalp. 

The recognition of the disease by the microscope is, however, 
the most certain method of establishing a diagnosis; and this is 
readily accomplished. Aubert, 2 in the absence of the clinical 
features named above, lays stress upon an intense redness of the 
scalp where the hairs have been cut and the crusts removed, this 
color being limited to the portions attacked by the disease. The 
hairs, also, as a result of the disintegration of their elements, 

1 Viertelj. f. Derm. u. Sypli., vii. p. 170. 

2 Armal. de Derm, et de ttyph., 2m. ser., 11, p. 34. 



508 DISEASES OF THE SKIN. 

are infiltrated by air, and look opaque and black by transmitted 
light. By reflected light, these appear polished and stratified. 
It .-diould not be forgotten that in exceptional cases, favus crusts 
coexist upon the body with other diseases of prior or subsequent 
origin, as indicated above. The disease should not be confounded 
with Beborrhcea, pustular eczema, or psoriasis of the scalp, none 
of which exhibit the special features of a parasitic fungus. 

Treatment. — The first indication in the treatment of favus is 
to thoroughly cleanse the surface of all favus and other crusts 
and seales which may be present. For this purpose the scalp (if 
this be, for example, the affected part) is first shorn of its hair 
with the scissors, and then thoroughly soaked in olive, cod-liver, 
or other oil, or glycerine After this, all the crusts are scraped 
away with a spatula, and the scalp washed clean with hot water 
and soap, the spirit of green soap being here preferably used. 
The scalp should be then again anointed with oil, or covered 
with an emollient poultice. Once thoroughly cleansed by re- 
peated soakings in oil and ablutions, it is necessary to resort 
either to the topical employment of parasiticides (agents capable 
of destroying the fungus) or epilation (the extraction of the 
hairs). Often both measures are required. Without further 
treatment, the scalp, however completely freed from all evi- 
dences of the disease, will not fail to show fresh favus crusts in a 
fortnight or somewhat longer time. 

Epilation is practised by the aid of epilating forceps. These 
should be constructed with an easy spring that will not tire the 
fingers of the operator; with blades that are sufficiently broad, 
to grasp a few hairs at once ; and with smooth, slightly serrated 
faces of the blades, as otherwise the hair is liable to fracture in 
the grasp of the instrument. The surface to be operated upon 
should be previously anointed with vaseline or olive oil, and the 
hairs be entirel}- removed, a sufficient number,covering a definite 
space, upon successive days. 

The tediousness of this process lias led to several devices, by 
which it is sought to do away with its necessity. Originally 
the "calotte" was employed for the removal of the hairs. It 
was made by smearing a disk of leather with pitch, and applying 
it over the scalp. When the calotte was subsequently removed 
by a brisk motion of the hand, the hairs which adhered were 
forcibly uprooted en masse; those remaining being adherent, in 
their sacs in consequence of the fact that they had not been in- 
vaded by the fungus. As a substitute for this somewhat brutal 
procedure, Bulkley 1 has employed adhesive masses, or sticks, 
which can be melted and made to adhere at once to large num- 
bers of the hairs. When cold they can be withdrawn from the 
surface with the hairs attached. These sticks are from two to 

1 Favus and its Treatment by a New Method of Dcpilation, Arch, of Derm., 
vii. No. 2, April, 1881. 



TINEA FAVOSA. 509 

three inches in length, and from one-fourth to three-fourths of 
an inch in diameter. The hair is first clipped so as to he about 
one-eighth of an inch in length. The end of the stick is then 
heated in an alcoholic flame, and quickly pressed upon the scalp. 
It is thus left in place till quite cold, and removed by bending 
it over and drawing upon the hairs successively with slight rota- 
tion. When free, it is found thickly set with the extracted fila- 
ments, which may be burned off in the alcohol flame, thus 
destroying both the hairs and any adherent fungous masses. The 
stick is then careful]}- wiped clean with paper, after which it is 
again ready for use. The formula for the mass of which these 
sticks are composed is as follows: — 



$. Cerse flavae 


3'ij; 


12 


Laccse in tubuiis 


^iv ; 


16 


Resinae 


3vj; 


24 


Picis Burgundicse 


~ X J; 


40 


Gummi dammar. 


§jss; 


48 



The parasiticides in greatest favor ;ire, corrosive sublimate in 
solution in the strength of two to four grains 0.13o-0.266 to 
the ounce (32.); sulphite of sodium in saturated solution; pure 
or diluted sulphurous acid; spirit of green soap; tar; carbolic 
and salicylic acids; petroleum; chloroform; ether; creasote; 
and the oil of cloves. Ointments are also useful containing mer- 
cury (citrine ointment, .yellow sulphate or white precipitate) 
tar, thymol, sulphur, and salicylic, pyrogallic and carbolic acids. 
Chrysarobin is very effectual as an ointment, though objection- 
able on account of the staining of the scalp, and, almost in- 
evitably, of the face also. Lenzberg generates sulphur fumes 
in a dish of red hot coals attached to a frame, made of wood or 
paste-board, close to the head of the patient. By means of a 
paper cap, the fumes are collected and retained for from five to 
ten minutes, in contact with the patient's hair. During ten 
years' trial of this plan, he has never been compelled to resort to 
epilation. 

One or more of the methods may be needed, either at the same 
time or by repetition or alternation, till the fungus is entirely 
destroyed, the requisite period usually extending over three 
months. Treatment should then be discontinued, in order to 
test the result by observation. If, in the course of a fortnight 
or more, a relapse occurs, the treatment is to be promptly re- 
newed. Upon the non-hairy portions of the body, parasiticides 
thoroughly applied usually procure a radical relief. When the 
nail is involved, it should be cut short and carefully scraped, 
after which a parasiticide may be employed in ointment or lotion. 

In genera], it may be remarked that patients long affected with 
rebellious favus, may need a roborant course of treatment and 
nutritious diet. Cleanliness here, as in all the parasitic disor- 

1 Der. prakt. arzt., Feb. 1881. 



510 DISEASES OF THE SKIN. 

rtere, is essentially important. As adjuvants in the treatment of 
the scalp and nails.it is well to remember that continuous appli- 
cations of a parasiticide are aided by caps or cots of impermeable 
material, bu peri m posed upon rags saturated with the medica- 
ment employed. 

Prognosis. — The prognosis is generally favorable to the ulti- 
mate termination of the disease in all cases; for even the most 
rebellious and untreated forms are relieved when the hair fol- 
licles atrophy. Upon the non-hairy portions of the body, the 
disorder is rarely severe if promptly and efficiently treated. 
Upon the scalp, the prognosis is proportioned to the extent, 
severity, and period of prior invasion of the disease. Early and 
vigorous treatment of the sculp in healthy children, is usually 
followed by satisfactory results. Ne<rlect, tilth, and sj-stenric 
malnutrition, are the most unfavorable elements in any case. 

Tinea Trichophytina. 

Deriv. Gr. 9f<£, hair ; ?i/tov, a vegetation. 
Ringworm is a disease of the hairs and hair follicles of the 
scalp and beard, as also of the non hairy portions of the body. 
In each case it is produced by the presence of the same vegetable 
fungus, the trichophyton. Inasmuch, however, as each of these 
regions of the body, when the parasite is present, displays lesions 
which are more or less peculiar to itself, it is usual to consider 
each separately. Ringworm of the body is hence designated, 
tinea cikcinata; of the scalp, tinea tonsurans; of the beard, 

TINEA SYCOSIS. 

Tinea Circinata. 
Tinea circinata is a contagious disease of the skin, characterized by macular, 
vesicular, papular, scpiamous, and rarely pustular lesions, having usually a 
clearly defined, circular outline, and induced by the presence of the tricho- 
phyton. 

Symptomatology. — Ringworm of the body displays different 
symptoms, according to the temperature in which the vegetation 
flourishes, and the various external irritants to which the skin, 
where it. has once been implanted, is subjected. 

The macular form of the disease is characterized by the occur- 
rence of one or several pea- to large coin-sized, circumscribed, 
reddish circles, usually paling under pressure, often at the gene- 
ral level of the integument, occasionally slightly raised above it, 
forming then a flattened disk. The centre of the circle may be 
paler, or indeed to the naked eye quite unaffected, transforming 
the patch to an annular lesion, from which circumstance it ori- 
ginally received the name, "ringworm." It develops within 
certain limits, rarely exceeding five or six inches in diameter, 
by peripheral extension; and is usually characterized at the 
outer border by slight, whitish, furfuraceous desquamation. 
This form of lesion is usually seen upon exposed surfaces of the 



TINEA TR1CHOPHYTIN A. 511 

body where there is less heat, moisture, and friction than upon 
others, as, for example, the forehead and neck in moderate 
atmospheric temperatures. From it may be developed the other 
forms described below. The disease may recur within the 
peripheral border; in this way occasionally two, three, and 
more concentric rings or parallel bands of crescentic outline 
may be visible in a single patch of disease. The subjective sen- 
sations are a trifling degree of itching or burning. Should these 
rings extend to the beard or seal]), the circinate may coexist 
with the other varieties of the disease. 

The vesicular lesions of ringworm appear as such at the onset, 
or rise from the macular lesions described above. In the former 
case, pin-point sized, transitory, and superficial vesicles or vesico- 
papules spring from a central point or focus, or speedily shrivel 
till they are represented merely by minute, whitish, branny 
scales. To these others succeed, always at the periphery, and to 
these again yet others, the rosy or reddened base on which they 
rest being sometimes slightlj* in advance toward the outlying 
skin. The enlarging circlets of disease proceed in their course 
to an evolution quite similar to that observed in the macular 
forms. The difference, due chiefly to a somewhat more active 
development of the fungus, is noted not merely in the type of the 
lesion, but in the slightly exaggerated pruritic sensations which 
are awakened. Rarely, both of the forms described are pre- 
sented with acute symptoms and extensive development, in mul- 
tiple patches spreading over the face, neck, trunk, and extremi- 
ties, accompanied by a slight febrile movement and moderate 
tumefaction of the affected surfaces. As a rule, the eruption is 
trifling; and may indeed be limited to a single ring, or very few 
circlets about the neck, terminating in the branny desquamation 
described; but in the severer forms the evolution of the disease 
may persist for months, and crusts form, whose fall leaves annu- 
lar pigmentations of temporary duration. 

The papular and rare pustular forms of the disease observe 
the same peculiarities with respect to the clearing of the centre, 
the annular appearance of the advancing area of involvement, 
and the production finally of scales and crusts. They represent, 
however, either a much more luxuriant vegetation of the fungus, 
or the irritation of the affected part by friction and heat, or, 
w 7 hat is probable, the cooperation of the two. They are hence 
most commonly observed upon the back, the belly, the inter- 
and infra-mammary regions, and the internal faces of the thighs 
and arms, in which localities they occasionally occur with chronic 
manifestations. The papules are light or dull reddish, pin-head, 
and larger, solid elevations, roundish, ovalish, irregular, or con- 
fluent, forming eventually bean to coin-sized, raised disks with 
a pale, exfoliating, or actively inflamed centre, the so-called 
"nummular" or "discoid trichopbytic erythema" of French 
authors. The itching is sometimes in these forms, severe; and 



512 DISEASES OF THE SKI ft. 

the process may display contra] recrudescence, as noted above. 
Pustules found at the periphery have the size and distribution 
of the other lesions described. They represent merely an aggra- 
vated exudative process awakened by the fungus, and the scratch- 
ing incident to the pruritic sensations excited. 

Partly because of the controversy which the stihject has 
aroused, special attention has been directed for some years to 
the disease which Hehra was first to name, ECZEMA MARGINATUM. 
It is most marked upon the portions of the body which come 
in contact with the saddle when a rider is mounted on a horse, 
that is, the perineum and the inner faces of the thighs, the region 
well marked hy the reinforcing patch in the trousers of the cav- 
alryman. The disease, as encountered here, is termed TINKA 
TRICH0PHYT1NA cruris, and occurs in both sexes. It is charac- 
terized by extensive exudation, in bright or lurid patches, with 
a very distinctly defined raised border, showing a sharp contrast 
with the healthy skin beyond, from which peculiarity it has its 
name. It may extend laterally over the groins, upward over 
the pubes, and backward over the sacrum, bein«r generally de- 
fined at the periphery hy a crescentic outline. The centre may 
he paler and less involved, or actively irritated, while the 
periphery still extends in one or more annular festoons down 
the inside of the thigh or upward over the regions indicated. 
The itching is severe; the course of the disease obstinate, per- 
sistent, and subject in a remarkable degree to relapse in the same 
locality. The fungus is always present, whether occurring as a 
cause or epiphenomenon of the disorder. It was rightly named 
by Hebra; and deserves special recognition under whatever title 
it be classified. It is a true eczema, with special features, com- 
plicated by the development of the fungus, and aggravated by 
heat, the moisture of the sweat, and the friction of apposed sur- 
faces of the skin in contact with each other and the clothing. 
I have occasionally detected the fungus in scales scraped from 
the surfaces thus involved, and am always in such case impressed 
with the characteristic clinical peculiarities of the disease. It 
is usually of symmetrical distribution, due to the circumstances 
of its development, and in this respect differs from the other 
manifestations of the disease. 

When the nails are affected, the disorder is termed tinea 
trichophytina unguium, or onyohomycosis. These appendages of 
the skin then become friable, opaque, and lamellated ; and are 
clinically indistinguishable from nails secondarily changed in 
eczema, psoriasis, and similar disorders of the integument. One 
or several of the nails of both feet and hands may be affected. 
When all the nails of both extremities are involved, the disease 
is rarely of parasitic origin. The microscope is requisite for 
establishing the diagnosis in such cases, the parasite being de- 
tected in the fragments procured by scraping the nail. 

Etiology. — The disease is caused by the presence of the para- 



TINEA TRICHOPHYTINA. 513 

site, though the latter ma) 7 be an accident of other cutaneous 
disorders. The trichophyton was first discovered by Gruby, in 
1844; though Malmsten, whose name is often associated with 
that of the fungus, became identified with its recognition, by 
his observations during the succeeding year. As a contagious 
disease, it ranks higher in the scale than favus, being much more 
readily communicated ; and, as a result, much more, common. 
Occurring upon th'e non-hairy portions of the body, it is often 
spontaneously removed by the desquamative process which it 
excites in the skin. 

Though the fungus is the essential cause of the disease, its 
development is greatly favored or retarded by external influ- 
ences. Attention has been already called to its luxuriance 
under the influence of heat and moisture. It is hence much 
more severe and rebellious to treatment in tropical countries. 
It occasionally occurs in epidemic forms. Thus G-erlier 1 gives 
the details of such an epidemic in Ferney-Voltaire, where 
twenty-six cases came under his observation. In some of these 
the lesions were pustular: in others, tuberculo-pustular. Ag- 
gravated forms of the disease seem also to originate in the lower 
animals. I have seen certain mild types of ringworm transmit- 
ted to man from cats and dogs. Gerlier concludes that the most 
rebellious and persistent forms are derived from the horse ; those 
from the cow being of less formidable character. Tilbury Fox 
reports an especially aggravated case originating in the disease 
as it existed upon a pony. It occurs much more frequently in 
children than in adults, presumably from the relatively tender 
condition of the epidermis in these subjects. It is particularly 
liable to occur in men whose skins are especially moistened, as 
in those who work in atmospheres saturated with steam. Sev- 
eral members of a single household will often display ringworm 
of the body at the same time, having transmitted it, the one to 
the other. Dub. ring and Fox are in accord respecting a belief 
in the need of an appropriate soil for the germination of the 
fungus, sonje individuals being thus predisposed to its inva- 
sion. It is, however, encountered in both sexes and in all social 
conditions. 

Pathology. — The seat of the fungus in tinea circlnata is between 
the strata of the epidermis, that part of it more particularly 
which lies immediately beneath the stratum corneurn, the su- 
perior layers of the rete. Here the trichophyton can be discov- 
ered with the microscope; at an early stage of the disease, in 
the form of spores only ; in the course of a few weeks, exhibit- 
ing characteristic mycelium. The latter is much more scantily 
developed than in favus: much less branched and reticular; 
and the threads more slender. Like the elements in favus, how- 
ever, these are jointed and divided into compound cells by par- 

1 Lyon Medical, April 24, p. 590, and May 1, p. 7, 1881. 
33 



514 



DISEASES OF THE SKIN. 



tition walls. The spores are also often strung together like the 
beads on a necklace. The former measure .0018 to .0026 mm. ; 
and the latter, .0021 to .0035 mm. (Duhring.) 

After the fungus lias found its way to the surface of the skin 
favorable to its development, it penetrates the layers of the epi- 
dermis In every direction from the central point of invasion. 
the circle thus produced being characteristic of many forms in 
both the higher and the lower vegetable lrfe. The irritation 
excited by the presence of this foreign body produces all the 
subsequent symptoms of a mild grade of superficially seated 
inflammation ; erythema, exudation and fine vesiculation, papu- 
lation, and, in the severe grades, the production of tubercles and 
pustules. The desquamative symptoms are exfoliative ; and rep- 
resent, in a sense, the natural effort at relief; this effort, as re- 
marked above, being often successful when the spores and myce- 
lia are thrown off with the effete, horny plates of the epidermis. 

Fig. 54. 








Wb 



r^ 



Epidermis invaded by the trichophyton, a, Inferior portion of the stratum corneum ; b, supe- 
rior portion of the rete. Both exhibit long mycelial threads, with few ramifications and a small 
anmber of spores. (After Kaposi.) 



When the nails are affected, the same fungus can be discovered 
in detritus of the nail-tissue, which has been macerated in dilute 
liquor potassas. Often, as a result, of the impairment of the 
structure of this organ, and owing largely to the stratification 
of its body, the lamella? will be found in part to have under- 
gone a caseous degeneration. 

Diagnosis. — Ringworm of the body is to be distinguished 
clinically from eczema, psoriasis, seborrhcea, lupus erythematosus, 
herpes iris, and syphilis. All the varieties of eczema are noted 



TINEA TRICHOPHYTINA. 515 

for their greater degree of itching and infiltration, their much 
less defined border, coarser scales, decided absence of a circular 
contour, and history of contagion. Psoriasis does occur in cir- 
cular and annular patches, often with a clear centre and insigni- 
ficant, subjective sensations. But its scales are lustrous, the 
tissue beneath them readily bleeds, showing deeper implication 
of the skin. The disease is often symmetrical in disposition ; 
occurs by preference upon certain regions of the bocfy where 
ringworm is relatively infrequent and its history is that of a 
chronic disorder. Seborrhcea of the skin exhibits greasy or 
fatty .crusts, which are never characterized by the peculiarly 
branny condition of the scales seen in ringworm of the body. 
The distinction between these disorders on the scalp will be 
given later. Lupus erythematosus is often symmetrical, always 
chronic, and characterized by firmly attached, 3-ellowish-gray 
scales. Though having often a circular outline, it is rarely if 
ever characterized by the development of multiple, annular 
patches, enlarging centrifugally from a clearing centre. Herpes 
iris can be distinguished, first, by its predilection for the ex- 
tremities; second, by the variegations in color which it dis- 
plays, and which are never seen in ringworm of the hands. 
Syphilis is multiform in its lesions, usually preceded by a his- 
tory of infection; and its distinctly circular patches, enlarging 
at the periphery, all exhibit either atrophic, ulcerative, or dis- 
tinctly crusted symptoms, which suffice for their recognition. 

But the microscopical discovery of the parasite is the chief, 
and indeed essential, method of diagnosis in tinea circinata. 
By the aid of a good fourth or fifth inch objective, the spores 
and mycelia are readily recognized in the scales scraped from 
the surface and moistened with dilute liquor potassaa. Duhring 
calls attention to the care which should be had in distinguish- 
ing the fungous elements from cotton or wool fibres, fat globules 
derived from previously applied unguents for the cure of the 
disease, sebum, pus, and the so-called nuclei of the epithelia. All 
confusion of this sort can be avoided by a careful study of the 
anatomical peculiarities of the trichophyton, recalling especially 
the parallelism seen in the double contours of the threads, their 
jointed appearance, their contained granules, and the necklace- 
like or beaded arrangement of many spores. 

Treatment. — The indication in the treatment of ringworm of 
the body, is the hastening of the exfoliation of the superficial 
layers of the epidermis, by which means the spores aud nryeelia 
are thrown off from the surface; and, if possible, their simul- 
taneous destruction. Upon the delicate skins of infants and 
children, the simpler remedies are first to be employed. Scrub- 
bing each patch with the spirit of green soap, or merely soap 
and water, will often suffice for its obliteration. The topical 
application of tincture of iodine is a common and usually ef- 
fective remedy. The same may be said of dilute acetic, boracic, 



516 DISEASES OF THE SKIN. 

and carbolic acids. Morris's solution of thymol, 1 half a drachm 
to two drachma (2.-8.) of chloroform, and six drachms (24.) of 

olive oil, is equally available. 1 have also used thymol in oint- 
ments, hall' a drachm (2.) to the ounce (32.) of simple unguent, 
with good effect. Of the mercurials, ammoniated mercury, a 
scruple (1.33) to the ounce (32.) of ointment ; corrosive sublimate, 
one to two grains (.066-0.183) to the ounce (32.) of solution; 
and thebintment of the nitrate, one drachm (4.) to the ounce 
['■',-.) of vaseline, are preferable. Sulphurous acid from a freshly 
opened can, and saturated solutions of the hyposulphite of 
sodium are, I believe, as effective as any of the parasiticides, 
and are often used with advantage as lotions to be followed by 
an appropriate unguent, always providing against chemical de- 
composition of the ingredients of the latter. Sulphur- and tar- 
containing lotions and unguents are useful in more obstinate 

eiises. 

Chrysarohin and pyrogallic acid, in ointment from five to 
ten grains (0.33-0.66) to the ounce (32. ), are brilliantly effective 
in all these cases, subject, however, to the disadvantage inci- 
dental to the staining and irritative effects they produce. They 
should be used with caution upon the skins of children, and 
always tentatively at the onset. In cases of ringworm on the 
face of male adults, close to the heard or scalp, I have employed 
these remedies with a view to insure the non-invasion of the 
pilary follicles by the fungus, who<e prompt destruction may 
become then a matter of urgency. Wilkinson's ointment, recom- 
mended by Kaposi, is also useful in the treatment of aggra- 
vated forms of ringworm of the body, but should he restricted 
to such cases. For other, and more urgent reasons, caustic 
potassa solutions should be reserved for exceedingly intractable 
cases. Sometimes a combination of several of the simpler re- 
medies named above may be serviceable, as in the following 
formula : — 

R. Lac. sulphur. 

Sapon. virid. spts. ) 
Lavandal. tr. J 

Glycerine 

The thorough application of the remedy selected for use, upon 
the integument quite freed from its scales by scrubbing with 
soap and water, is a matter of some importance. When the 
solution of sodic hyposulphite is employed, the previous appli- 
cation of dilute vinegar and water by sponging, renders the 
agent more effective, for evident chemical reasons. Overtreated 
skins, or those to which too strong a parasiticide has been ap- 
plied, require subsequent relief of the induced irritation by the 
simpler bland dressings. The inert dusting powders, even when 

1 Lancet, 1881, pp. 104 and 241. 



5'jss; 


10 


aa 5vj ; 


24 


5 ss ; 


2 M. 
(Kaposi.) 



TINEA TRICHOPHYTINA. 517 

not thus indicated, are often useful when there is distinct vesicu- 
lation ; and in simple cases may be the sole remedies required, 
as then the disease is self-limited in duration. 

Liborius, 1 having observed in China that the tincture of an 
unknown fibrous root was used successfully as a remedy for 
ringworm, obtained some of the plant, which was found to be the 
Rhinacanthus communis, whose leaves, bruised and mixed with 
lime juice, are used in India as an application for the same com- 
plaint. Liborius has since obtained from the root a quinine- 
like body, supposed to be the active constituent. It resembles 
chrysophanic acid in being antiseptic and anti-parasitic. He 
proposes to call it rhinacanthin, and represents it by the formula 
C 14 4 18 4 . 

The internal treatment of patients affected with ringworm, by 
means of tonics and roborant measures, may be demanded by 
the systemic condition, but has no recognized influence over the 
disease itself. 

When the nail is involved it should be thoroughly scraped, 
and then kept moist by wearing over it the rubber cots sold in 
the shops for the use of sportsmen, fishermen, and others. In 
this way a partial maceration of the nail substance is secured, 
and the action of any one of the parasiticides named above, 
greatly aided. 

Prognosis. — The disease is often self-limited ; and is generally, 
under the simplest treatment, satisfactorily relieved. Eczema 
marginatum, especiully in the crural region, may be obstinate ; 
and this because it is an eczema as well as a parasitic disease, 
and therefore subject to the relapses and chronic phases of the 
first-named disorder. Other intractable forms of the malady do, 
however, occasionally occur in adults, usually in tropical cli- 
mates and tropical temperatures. 

Tinea Imbricata. Tokelau Ringworm. Burmese Ringworm. 
Malabar Itch. — Under these names and others of similar cha- 
racter, have been described exaggerated forms of cutaneous dis- 
ease produced by a vegetable parasite whose identity with the 
trichophyton, though not established, is highly probable. Mc- 
Call Anderson, of Glasgow, 2 believes that the Tinea imbricata, 
described by Manson ; the Tokelau Ringworm, described by 
Turner; and the affection reported by MacG-regor as occurring 
in the Soloman Islands and the ISTew Hebrides, are all identical. 
The parasite does not extend deeply within the corium, but is 
found in luxuriant vegetation with preponderance of rather irre- 
gularly contoured spores. The clinical symptoms are, exagger- 
ated desquamation in ichthyotic flakes; the formation of con- 
centric rings by recrudescence of the disease within its annular 

' Therapeutic Gazette, September, 1881, p. 7. r -0. 
2 Edinburgh Med. Jour., 1880 1881, xxvi. p. 204. 



518 DISEASES OF THE SKIN. 

limits; the production of large festoons of lesions even upon the 
exposed surface of the face; and evidence, at times, of excessive 
irritation of the skin excited by the fungus, in the form of pus- 
tular and even furuncular and tubercular lesions. 

Tinea Tonsurans. 

Tinea Tonsurans is a cutaneous disease of the scalp, characterized by the occur- 
rence of one or several, circumscribed, non-elevated or tumid patches, over 
which the hairs are usually fractured at a point near the integument, pro- 
ducing thus the effect of partial baldness, while the scalp itself is the seat of 
vesiculation, sealing or crusting, the disease being produced by the presence 
of the trichophyton. 

Symptomatology. — The differences to he particularly noted be- 
tween ringworm of the body and ringworm of the scalp, depend 
largely upon the fact that in the latter, the fungus makes its way 
to the hair follicles and there finds the nutriment for its multi- 
plication and development. 

It is usually tirst observed in the form of circumscrihed, small 
coin-sized, roundish patches upon the scalp, wholly or partly 
covered by minute, whitish, slate-colored, grayish or dirty-yel- 
lowish scales. Rarely, the formation of the latter can be noted 
as consequent upon an hypenemicand reddened condition. Still 
more rarely, pin-point sized, transitory vesicles or pustules pre- 
cede. The hairs upon such a patch seem irregularly clipped 
short near the surface or, as it is frequently styled, "nibbled" off, 
thus producing the effect of partial baldness in the involved area. 
Among them may be often found long and fragile hairs, which 
break upon slight traction or bending. The patches may increase 
in number and spread individually in area till, in the course of 
weeks or mouths, the entire scalp is invaded. In the older 
] latches, young and downy hairs may be seen here and there, 
pushing upward among the stumps left by those that have fallen. 
One or more of various phases of the disease may be presented 
in its subsequent evolution. Thus a single patch may extend 
to the size of a large coin or the palm, and the disease be 
throughout limited to that area. Again, as just related, almost 
the entire scalp may be covered by relatively small or enlarging 
patches, or, even without the occurrence of any distinct patch, 
isolated hairs or tufts of hairs here and there over the entire 
scalp may exhibit evidence of impairment. The disease may 
be acute or chronic in its course. Instead of assuming the dry 
and squamous type described, acute and exudative symptoms 
may develop, in which event the rare vesicular and pustular 
lesions are succeeded by the exudation of a gummy secretion 
and the formation of crusts. Lastly, the variety known as 
kerion may be produced, which is described below. 

Pruritus, in various grades of severity though usually mild, 
is induced by the disease; and often the patches are altered in 



TINEA TRICHOPHYTINA. 519 

appearance by the traumatisms produced by the finger-nails and 
the comb. When the scalp is very generally invaded by the 
squamous form of the disorder, its appearance is very similar to 
that noted in diffuse seborrhcea, chronic eczema, and psoriasis 
of the scalp, except that the hairs are less pasted to the surface; 
more lustreless, friable, and contorted in shape; and much more 
often represented bj - stubble or stumps. The disease may occur 
coincidently with ringworm of the body, and indeed at times a 
ring may be detected, half of which on the neck presents the 
typical aspect of tinea circinata, and the other half involving 
the scalp exhibits the features here described. Stowers, 1 Sang- 
ster, 2 as also Hutchinson, Tay, Hillier, Baker, and others have 
recorded cases in which the disease coexisted with alopecia 
areata. I have certainly observed this occurrence but in one 
case, where to me the evidence was conclusive that there was 
mere coincidence and no causal relation between the disorders 
named. 

Lastly, it is to be noted that here also at times the efforts of 
nature are successful in procuring spontaneous relief. With the 
defluvium capillitii and exfoliating epidermal plates, the fungus 
may be finally removed; the resulting alopecia be followed by 
a growth of healthy pilary filaments; and, even though 3'ears 
be required for this long process, in the end no trace of the dis- 
ease be discernible. 

Etiology. — Ringworm of the scalp is produced by the same 
fungus as that recognized in the etiology of tinea circinata, the 
trichophyton. It is frequently observed in children of both 
sexes, especially in those gathered together in schools and public 
Charities, where it may spread very generally from one to another 
and require months and years for its extermination. It is a 
more highly contagious disease than favus, and yet requires 
unquestionably a suitable soil for its development. 1 have been 
frequently impressed with a fact in this connection to which 
Dr. White 3 calls attention. When there is ringworm on the 
face of an adult even of rebellious form, in the course of which 
the beard of the male may be extensively affected, the scalp is 
usually spared. Ringworm of the scalp in the adult and aged, 
is indeed among the rarest of cutaneous accidents. Among the 
methods of transmission in children are, the use upon the heads 
of the unaffected of brushes, combs, wearing apparel, sponges, 
towels, etc., which have been employed upon persons exhibiting 
ringworm of the' body or head. It must be remembered that 
tinea circinata may transmit tinea tonsurans; and it is by 
tracing the course of the two forms of the disease, that the 
sources of contagion can be ascertained in any series of cases. 
The disease is one rather prevailing in the cities than in the 
country; and in this respect also differs from favus. 

1 Lancet, 1831, p. 326. 2 Id., 1880, p. 303. 3 Loc. cit. 



520 DISEASES OF THE SKIN. 

Pathology. — The disease is produced in consequence of the in- 
vasion of the Bcalp, and follicles, bulbs, and shafts of the hair, by 
the trichophyton, the fungus already described as the cause of 
tinea cireinata. This vegetable mould is much more abundantly 
developed about the hairs than theachorion Schonleinii, and its 
presence is hence much more readily demonstrated in these 
structures. 

Pie. 55. 















■'■^rc 



m^m. 




Hair invaded by the trichophyton. 

Robinson 1 has lately excised a portion of a scalp affected with 
tinea tonsurans; and found the stratum corneum, especially in 
its upper layers, largely invaded by spores, as also the rete, the 
external root-sheath of the hairs in its upper portion, the corium, 
and subcutaneous tissues. Mycelia were abundant in the mucous 
layer. He concludes that the anatomical seat of the disease dif- 
iers in different cases. 

Under the microscope the hairs themselves, in advanced cases, 
are seen to be greatly altered. The bulbs are distorted, mis- 
shapen, or withered, and often stuffed with spores which greatly 
predominate over the mycelia. At times the base of the bulb 
will show a brush-like expansion, and in this respect resemble 
the free ends of the stumps of the hairs above, which have a 
jagged, bristle like appearance, from the division of the shaft 
into many filaments between which spores in abundance are 
visible. The shaft is often longitudinally split, where the para- 
sitic growth has mechanically forced apart its-elements, and its 
cuticle may be peeled off, or curled above and below away from 
the axis, with spores protruding at such points. Conidia can be 
discovered much further upward along the hair and distant from 
the scalp than in favus; often indeed upon its free surface. Oc- 
casionally a few mycelial threads may be recognized, either 

1 New York Mod. Journal, 1881, vol. xxxiii. p. 289. 



TINEA TRICHOPHYTIN'A. 521 

longitudinally or transversely arranged as regards the axis. It 
is probable, however, that the relative preponderance of spores 
and raycelia in these filaments is determined by the stadium of 
the disease in any given case. In the earlier stages of the disease 
the elongated threads may be discovered in larger quantity; 
and as they interfere less with the integrity of the fibrous tissue, 
the hair may usually at these times be extracted from its follicle 
without fracture. Later, the threads disappear and the conidia 
are infiltrated throughout every portion of the shaft which then 
breaks, often upon the slightest traction. One unaccustomed 
to microscopical examinations, with a view to the detection of 
the parasite, should be careful not to mistake for these threads, 
the delicate lines traversing the surface of the shaft exposed to 
the objective, and which represent the edges of the cuticle of 
the hair The fungus, though ordinarily refractory to the 
action of coloring matters, will be stained by eosine and methyl- 
violet. The scales found upon the affected scalp also exhibit 
traces of* the trichophyton under the microscope, though to a 
less extent than the invaded hairs. In exceptional cases, how- 
ever, the epidermis of the scalp seems to suffer as much as that 
of the non-hairy portions of the body. 

Diagnosis. — The recognition of a typical patch of ringworm 
of the head is simple. The branny scales, stumps of hairs, and 
distinct contour of the invaded area, are always in the highest 
degree suspicious symptoms. It has been stated, however, that 
the general development of tinea tonsurans over the scalp pro- 
duces a condition very .like that seen in other diseases. In such 
cases the microscope must be employed for a decision as to the na- 
ture of the process. I have seen the whole vertex unnecessarily 
epilated in seborrhcea sicca, when no parasite could be found. 
But in seborrhcea there is usually a symmetry of involvement 
which even aggravated cases of ringworm of the head fail to 
assume; and even though pasted down, atrophied, changed in 
color, and loosened in their follicles, the hairs are rarely broken 
off near the scalp in seborrhcea. In seborrhcea, psoriasis, and 
squamous eczema of the scalp, there is, moreover, no history of 
contagion; the scales are in each disease different in color and 
character; and the hairs in the two last named affections, are 
firmly seated in their follicles, and only in severe cases present 
nutritional changes. The diseases, moreover, are usually chronic 
in their course. In any doubtful case, apart from microscopical 
evidence, thorough removal of all scales from the scalp by sham- 
pooing with green soap and hot water, will reveal the nature of 
the disease present. 

t Alopecia areata, as has been noted above, may coexist with 
ringworm, but is pathologically distinct from it. The patches 
in the first-named disease are uniformly smooth, and the hair 
falls from them en rnasse, without lesions, stumps, or other traces 
of its former development in the region affected. I have, how- 



522 DISEASES OF THE SKIN. 

ever, often seen blackish points or dote distributed over the areas 
which characterize this form of alopecia, and which certainly 
constitute suspicious symptoms in any case. In such event, I 
have, with a tine needle, been able to pick out this blackish 
point from the patent follicular orifice, and found it to be a 
particle of dust accidentally lodged in the depression. It is 
not, as in comedo, free pigment which has found its way to the 
surface; nor, as in ringworm, the stump of a hair on a level 
with the superficies of the scalp. In favus, the cup shaped crust 
will sooner or later betray the character of the disease to the 
naked eye. 

Confirmatory evidence as to the nature of the disease will 
often be furnished by a careful search for the source from 
which it was derived; and for obvious reasons this should he 
always attempted. Ringworm of the body occurring upon the 
individual patient affected with tinea tonsurans, or other mem- 
bers of the same household, and suspicious "mangy" patches 
upon horses, dogs, cats, rabbits, white mice, or other animals 
with which the child may have been in contact, should always 
receive attention. 

Treatment. — The indication for the relief of the disease is the 
destruction of the parasite; and there can be no question but 
that this may be accomplished in some cases without having- re- 
course to epilation. The parasiticides named in connection with 
ringworm of the body, if thoroughly applied in simple cases, after 
clipping or shaving the hair and an efficient scrubbing of the 
patch with spirit of green soap and water, w T ill occasionally be 
followed by permanent relief. Prominent among these parasiti- 
cides may be named : sulphurous and horacic acids, saturated 
solutions of the sodic hyposulphite, acetuvn cantharidis, tinc- 
ture of iodine, Morris's solution of thymol in chloroform and 
olive oil (see tinea circinata), ointments of boracic acid and sul- 
phur of each a drachm (4.) to t lie ounce (82.) of vaseline, and 
chrysarobin, the action of the latter being carefully limited to 
the patch of disease by the aid of a skullcap. 

Epilation is, however, a valuable, and occasionally essential, 
method of treating the disease; and may be practised as already 
recommended in considering the treatment of favus. The scalp 
in each case should be first oiled, and cleansed by the soap sham- 
poo, and after the epilation is performed, an appropriate para- 
siticide should be employed. The calotte, made by spreading 
pitch plaster upon leather or muslin, may be substituted for 
epilation in order to remove the hairs, as also the sticks recom- 
mended by Bulkley, the formula for the preparation of which 
has been already given. In each case, the epilation should re-' 
move a zone of sound hairs encircling the diseased patch, that 
the encroachments of the fungus may be in every possible way 
limited. It should not be forgotten, however, in the treatment 
of tinea tonsurans by both epilation and parasiticides, that in 



TINEA TRICHOPHYTINA. 523 

chronic cases these methods, in the hands of the most expert, 
have failed for consecutive months, to radically relieve the dis- 
ease; that even the most inveterate cases, in the course of time 
and as adult years are reached, are spontaneously relieved with- 
out permanent alopecia; and that no remedy or procedure is 
ever justifiable which is capable either of producing follicular 
atrophy, or an effect worse than that wrought by the disease 
itself. 

The induction of suppuration in the hair follicles (or a species 
of artificial kerion) by the aid of croton oil liniment-, has been 
praised by Alder Smith and Wyndham Cottle, of London, and 
lately, in a modified form, by Magee Finny, of Dublin. By the 
latter process, one hundred parts of the oil are mixed with fifty 
each of caoio butter and white wax. Sticks are made of the 
compound which can be thoroughly rubbed into the part affected. 
By both methods, it is claimed that no pain is produced, nor is 
permanent alopecia the result. A solution of salicylic acid is 
applied after each treatment, and a subsequent poultice may be 
also needed. In these cases, the parasite is presumably destroyed 
by the suppuration excited. 

Coster's paste is popular among English practitioners, including 
S.tovvers, Fox, Liveing, and others. It contains two drachms, 
(8.) of iodine in crystals, slowly dissolved in the oil of tar; and 
is painted over the part at intervals of a few days. It is most 
useful in circumscribed patches of the disease. Among other 
remedies employed, some of which have been described in con- 
nection with ringworm of the body, may be named, the corro- 
sive chloride, ammonio-chloride, red oxide, oleate, and ointment 
of the nitrate of mercury; pure carbolic acid and carbolated 
glycerine; and sulphur, chloroform, ether and tar in ointment. 

In order to be effectual, the treatment pursued must be per- 
sistent, thorough, and always accompanied by frequent washings 
and soapiugs of the affected part. 

As in the case of ringworm of the body, tinea tonsurans is 
not remediable by internal treatment. Such internal medication, 
however, may be indicated by the systemic condition of the 
little patients, and should be in each instance such as that con- 
dition suggests. 

Prognosis. — The ultimate prognosis in every judiciously treated 
cnse of tinea tonsurans is favorable, since all patients ultimately 
recover from the disease -per se. Under the best treatment many 
cases will prove tedious, month after month passing without 
marked improvement. The disease, however, in a large pro- 
portion of cases among children surrounded by proper hygienic 
conditions, especially as regards cleanliness, is readily relieved. 



Tinea Kerion. — The occurrence of active inflammation in a 
usually circumscribed portion of the scalp affected with ring- 



-V24 DISEASES OF THE SKIN. 

worm. 1? at times followed by certain peculiar features, the 
assemblage of which has been designated by this term. This 
complication of the disease was recognized early in the history 
of medicine, by Celsus, who^e name has since been associated 
with its lesions (Kerion Celsi, from xtjpiov, a honey-comb.) Til- 
bury Fox, in 1866, was first to recognize its identity with tinea 
tonsurans; and it has since been the subject of a number of in- 
teresting papers hy Tanturri, Maiocchi, Schilling, Bardazzi, 
Auspitz, and Wilson. In this country, Dr. I. E. Atkinson, 1 of 
Baltimore, has made it the Bubject ot a valuable memoir. 

The symptoms are, the occurrence of acute inflammation, usu- 
ally circumscribed, though occasionally diffuse, in a portion of the 
scalp where a tumor forms, which may project to a considerable 
distance above the general level. In time the appearance pre- 
sented is quite BUggestive of anthrax, as from the tumid orifices 
of numerous distended follicles, a viscid, semi-transparent and 
puriform fluid exudes. The latter is highly characteristic. The 
hairs loosen and fall. When the view of the tumor is not ob- 
scured by the pilary growth, it appears as a flattened lien's to 
turkey's egg-sized, boggy, semi-globular tumor, its surface con- 
gested, reddened, glazed, and often exhibiting other evidences 
of inflammation, with split-pea sized, pustule-like lesions dis- 
tributed over its surface, or, when these have ruptured, the 
gaping apertures described above, from which the gummy secre- 
tion is poured in varying quantities. Modifications of this con- 
dition occur, such as the production of a true subcutaneous 
abscess with fistulous sinuses. The sensations awakened are 
usually painful ; the course of the disease is chronic. It may 
begin with the usual symptoms of ringworm of the head, though 
often there is no history of the latter. The complication is a 
rare one. But five cases in all have come under my observation; 
two of these were cl 
a neighboring State. 

The parasite may and may not be found in patches of kerion, 
according to the acuity of the present or precedent inflamma- 
tory process. If the latter be of high grade and suppuration 
result, the fungus is destroyed, a result whose attainment has 
been attempted in the production of an "artificial kerion" by 
means of croton oil for the relief of tinea tonsurans. In the 
earlier stages, well described by Atkinson, and represented by 
merely deep-seated follicular inflammation, with pustular devel- 
opment about the hair-shafts, the latter may be seen microscopi- 
cally to lie invaded with spores. 

The treatment is either by the milder parasiticides or by the 
methods proper for the relief of ordinary phlegmonous inflam- 
mation of the scalp, according to the stage of the kerion. 

' Arch, of Derm., vol. vii. No 1, Jan. 1881. 



TINEA TRICHOPHYTON A. 525 

Tinea Sycosis. 

Tinea sycosis is a contagious disease of the region covered by the beard of the 
adult male, in which the integument, hairs, hair-follicles, and subcutaneous 
tissues may be involved, characterized by the occurrence of macular, papular, 
vesicular, pustular, or tubercular lesions, owing to the presence of the tricho- 
phyton. 

Symptomatology. — The disease is best studied at its onset, in 
the beard of a blonde subject with relatively tine downy hairs, 
where are presented the typical features of tinea circinata, ring- 
worm of the body. One or several, reddish, pea- to small coin- 
sized rings become visible, with pin-point sized vesicles, branny 
scales, and often indeed no other lesion save an hypertemic, 
scarcely elevated margin at the periphery. The hairs over the 
patch may be fragile, and clusters here and there betray evi- 
dences of change. With proper treatment the disorder may 
not progress beyond this point. 

In other cases, the very slight degree of itching awakened by 
the process just described, may be intensified, and large plaques 
form, a portion of which may extend from the region of the 
beard over the face and neck, or vice versa. When fully devel- 
oped, a phlegmonous disorder is produced which bears some 
analogy to the kerion just described, and which may so actively 
progress that it is first seen in typical development. The skin 
is congested and reddened, with sub-epidermic (or debris of rup- 
tured) pustules at the orifices of the pilary follicles; and is 
studded irregularly with firm, pea- to nut-sized papules and 
tubercles. The latter are usually aggregated in masses or lumps 
which involve the skin and subcutaneous tissues; and are firm, 
often tender and painful, rarely boggy and furuncular. These 
composite lesions are usually circumscribed in a given area of 
involvement, very rarely covering the region of the beard in 
symmetrical disposition, more often limited to one cheek, or the 
cheek and chin. Duhring has an admirable portrait of this dis- 
ease in his Atlas, one of the most faithful representations of a 
cutaneous affection which it is possible to produce. 

The hairs in the invaded region are involved as in ringworm 
of the scalp. These filaments break near the surface of the 
integument, leaving ragged stumps ; or spontaneous!}' fall, after 
being loosened in their follicles. In either event, the resulting, 
gradual thinning, or removal of the hairs, renders the disease of 
the surface more conspicuous and deforming. At the edges of 
a patch thus exposed, deformed, lustreless, contorted, flattened, 
twisted, or split hairs may be found. Occasionally the features 
of the patch are changed in consequence of the unusual degree 
of suppuration excited. In such case the pustules burst, and 
their contents concrete into dry crusts about the stumps of 
shafts of surviving hairs, from which circumstance the disease 
has received its name (sycosis, avxov, a fig). Rarely, a conglome- 



528 DISEASES OF THE SKIN". 

rate crust covers the entire Bar face with an excoriated, inflamed, 
and secreting surface beneath. 

Etiology. — The disease is always produced by the trichophyton, 
the fungus described as the cause of ringworm of the body and 
Bcalp. It was first described by Gruby, in 1844. Dr White, 1 
of Boston, lias called special attention to the frequency of its 
origin in the barber shop, a fact which common experience veri- 
ties It is usually the irregular visitor to these establishments 
who is first to supply the germs of the disease. No individual 
proprietorship in nine-, son}), brushes, and razor can secure, 
against danger of infection, the person whose razor is drawn 
over a common strop, whose cheek is handled by unwashed 
fingers which have been recently passed over an infected lace, 
or whose beard is combed, brushed, or rubbed by the implements, 
and towels in common use at these establishments. The remedy 
is twofold ; first, the full beard should he worn without shaving, 
as it is very rare to rind bearded patients of this class affected 
with tinea sycosis; second, where the whole or any part of it 
is to he removed, every adult male should learn to shave him- 
self. The physician should, in this connection, be for medico- 
legal reasons put upon his guard against hastily deciding both 
as to the nature of the disease of his patient and the source 
from which it was derived. Of the first, he can become cer- 
tain by his microscopical investigations. Of the second, he can 
oid} 7 become certain by obtaining possession of facts far beyond 
the reach of the average practitioner. A medical gentleman in 
a neighboring State recently sent me for examination some hairs 
from the beard of a male patient affected with tinea sycosis. 
Before receiving my report confirming his diagnosis, he was 
sued by the barber, in whose establishment the disease had been 
probably acquired, on the ground of libel. 

It is difficult to determine the frequency of the disease from 
statistics. The affection is certainly relatively rare, and yet 
more common, I am inclined to believe, than is frequently sup- 
posed to be the case. In my own practice it is of irregular oc- 
currence, months passing without a single case coming under 
observation, after which several may be noted in rapid succes- 
sion. I have had for example three cases during the month 
preceding the date of this writing, and these the only instances 
presented to my observation in half a year. 

The disease, being contagious, is one affecting men in all sta- 
tions of life, and these usually at a period rather under than 
over the fortieth year. I have certainly treated for this disease 
more men with light hair and oyc^, and light brown, reddish, 
or sandy beard, than those having darker shades of hair and 
eyes, a fact to which Mr. Morris has called attention in connec- 
tion with tinea tonsurans. 2 

1 Loc. cit. 2 Lancet, 1881. pp. 1G1 and 241. 



TINEA TRICHOPHYTINA. 



527 



Pathology. — The di sense is essentially a follicular and perifol- 
licular inflammation, induced by the irritative effects of the 
fungus, precisely as in the case of tinea tonsurans. The reason 
for the difference between the clinical aspects of' the two dis- 
eases, may be in part explained by the habitual covering of the 
scalp with caps and hats, while the face is left exposed ; and by 

Fig. 56. 




Filaments and spores of the trichophyton from the beard of a male patient affected 
with, tinea sycosis. 

the occurrence of tinea sycosis in adult years, while tinea ton- 
surans is emphatically a disease of childhood. As a result of the 
induced inflammation, the vesicles, pustules, papules, and tuber- 
cles are formed, while the perifollicular inflammation may in- 
vade all portions of the skin and subcutaneous tissues, gluing 
together the plastic nodules formed about the individual hair- 
sacs, into the lumpy masses which are so characteristic of the 
disease. The invasion of the hair follicles and hairs by the 
fungus, is accomplished as in the case of ringworm of the scalp. 
Under the microscope, spores and mycelia are visible, the former 
preponderating at the stage where the disease first comes under 
observation, but probalny preceded in most cases by abundance 
of thread-like forms. The identity of the disease with ring- 
worm of the body and scalp, does not, however, rest merely upon 
microscopical observation, but is demonstrable by established 
clinical facts. Not only may ringworm be seen to spread from 
the face to the beard, but tinea tonsurans and tinea circinata 
may transmit tinea sycosis, and the reverse. I lately treated a 
physician for ringworm of the bearded chin and cheek derived 
from the face of a little patient under his care. He subsequently 
gave tinea circinata to his wife, who suffered on the face and 



528 DISEASES OF THE SKIN. 

shoulder, and she. iu tarn, communicated tinea tonsurans to her 
daughter. 

Diagnosis. — The distinction between the parasitic and non- 
parasitic forms of sycosis, is of chief importance in this connec- 
tion; and, necessarily, the microscope must he employed to 
Bet tie the question definitely. The diseases, however, differ in 
their clinical features. The non-parasitic form always tails to 
exhibit the nodules, tubercles, and composite cutaneous and 
subcutaneous agglutinations of the disease produced by the 
fungus. The disease in the former is a more superficial pro- 
cess and, in my experience, exhibits to the eye a more vivid 
redness as a result of the cutaneous hyperemia. Owing to the 
same cause, the frequent pus- containing lesions are developed 
and elevated above the general level of the integument; they 
are less commonly sub epidermic crypts filled with characteristic 
mucoid puriform contents. The region of the bearded upper 
lip, so often involved in cases of chronic nasal catarrh with 
coryza, is apt to he spared by the trichophyton. When the 
latter is present, the hairs are characteristically loosened, dis- 
torted, and otherwise changed. This is not seen in the non- 
parasitic form of the disease. Exception, however, in this par- 
ticular is to be noted in some long standing cases of non-parasitic 
sycosis. When the latter affection has persisted for many years 
(and I have treated such patients), one is struck with the thinned 
and starved condition of the pilary growth, the scanty lustreless 
hairs often scarcely sufficing to conceal the deforming redness 
and pustulation of the surface from which they spring. In an- 
other point, my personal experience seems to differ from that of 
some other observers. The diffuse symmetrical affection of the 
hairy face, extending over both cheeks and chin, has been by 
me more frequently recognized as unconnected with the presence 
of a parasite. Lastly, the parasitic is, as a rule, less painful and 
tender than the other form of sycosis; and is, without question, 
furthermore of much rarer occurrence. 

As distinguished from syphilis, it is to be remarked that the 
papular or pustular syphiloderm developed in the beard is, al- 
most without exception, to be discovered in other parts of the 
body, especially the scalp. Ringworm of the scalp and beard, 
existing at the same time in one individual, I have never seen. 
In syphilis, there is usually an offensive odor to the abundant 
crusts; shallow ulcers are also apt to form beneath the pustules; 
and there is often a history of infection or a hint of the nature 
of the disease in its polymorphic character. 

Eczema of the bearded region may extend to or from other 
portions of the face, as in the case where it sweeps down from 
the ear above. The presence of a stalactitic crust, depending 
from the lobe of the ear of an affected side, would at once fur- 
nish a clue to the nature of the disease in the beard. In eczema, 
the interfollicular region is invaded; not deeply, as in tinea, 



TINEA TRICHOPHYTINA. 529 

but superficially, as in non-parasitic sycosis. The itching is 
severe; the hairs not involved ; the infiltration diffuse; the out- 
line indeterminate; and a halo of redness spreads from the 
affected part to the non-hairy surface in the vicinity. 

Treatment. — The treatment of tinea sycosis is generally con- 
ducted as in tinea tonsurans. It is customary to begin by 
anointing the affected surface with an oily or fatty substance, 
and to follow this with a shampoo of soap and warm water for 
the removal of crusts, after which shaving and epilation are 
practised on alternate days; and parasiticides employed locally. 
For the softening of the crusts, the spray of the atomizer may 
be used. 

Epilation of the male beard is often essential for the removal 
of the disease, but I believe that the results of the treatment 
suggested helow, are in the end often as satisfactory. It is true 
that a month or more may be required for the removal of the 
disease, but this is often the period of time during which treat- 
ment by epilation must be pursued. 

The patient for two successive days keeps the affected part 
macerated with almond or olive oil. On the evening of the 
third day, the shampoo with soap is employed, and the skin 
washed free of all crusts and scales. The part is then cleanly 
shaved. The first is more painful than any subsequent similar 
operation. After the shaving, the affected surface is bathed for 
ten minutes in water as hot as can be tolerated, by which means 
the inflammatory condition of the perifollicular tissues is, in a 
brief time, considerably reduced. While the bathing is in pro- 
gress, all sub-epidermic pustules or points where a mucoid fluid 
is coming to the surface, are opened with a fine needle. A solu- 
tion of the hyposulphite of sodium is then sponged freely over 
the surface for several minutes. This may contain a drachm (4.) 
to the ounce (32.) or even more. After a thorough and final wash- 
ing with the hot water, the tender skin is carefully dried and 
gently smeared with a sulphur ointment, containing one or two 
drachms (4.-8.) to the ounce (82.) of vaseline. The patient then 
retires to bed. In the morning, the unguent is washed off with 
soap and water, the sodium solution reapplied, and an inert pow- 
der thoroughly dusted, and kept over the part during the day. In 
the evening, the shaving maybe repeated or not, according to the 
vigor with which the beard is reproduced, but on the second day 
this is imperative. As soon as the pustulation ceases and the 
tubercles have manifestly diminished in size, the ointment at 
night is superseded by the use, at that time also, of the dusting 
powder. Whether the shaving is practised nightly or on alternate 
nights, the ablution with very hot water and with the solution 
of the hyposulphite of sodium, is continued nightly till the in- 
flammation excited by the fungus is practically limited to the 
follicles which are invaded. The dusting powder is to be thor- 
oughly and constantly employed after the ointment is discon- 
34 



530 DISEASES OF THE SKIN. 

tinned. With care and patience, I have succeeded by these 
men 8 urea in Baviug a number of patients from the annoyance of 

epilation. The treatment should be continued for several weeks 
after the apparent relief of the disease. 

The treatment may be varied to suit the needs of individual 
cases. Kaposi highly recommends, for example, one per cent. 
solutions of corrosive sublimate locally; and the other parasi- 
ticides considered heretofore in connection with the treatment 
of rfngworm, may serve here also a good purpose. I have used 
an ointment of thymol in two cases with manifest advantage, 
and should not hesitate in others to employ Mr. Morris's solution 
of the same in chloroform and oil. The formula for this has 
been already given. In other cases, the stimulating spirit of 
green soap with sulphur; finely powdered sulphur; boracic, 
acetic, and, carbolic acids ; or other topical applications of recog- 
nized value may he employed. 

When resort is had to epilation, and this is essential in all 
severe cases, the hairs should ho thoroughly removed from their 
follicles over every lumpy nodule, and even over every suspicions 
patch covered with scales. A zone should be cleared about each 
such papule. The results are prompt, and in the highest degree 
satisfactory. 

Prognosis. — This disease is always remedied sooner or later, 
though at times tedious in its progress, and characterized by 
relapse. 

Precautions to be observed in the General Management 
of Tinea Favosa and Tinea Trichophytina. — The physician. 
consulted in the case of a patient affected with either of the 
diseases thus far considered as resulting from the presence 
of a vegetable parasite, should bear in mind that they are 
the most highly contagious of their class. lie may not only 
himself suffer trom the disease which he is attempting to relieve 
in another, but also convey it to others himself, or be consulted 
by others of his patient's family, actually infected during the 
course of the treatment pursued. 

Generally it may he said that the hands of the physician 
should be carefully washed after each manipulation of the part, 
and preferably by aid of a weak disinfecting solution. When 
practicable, infected individuals should occupy separate beds; and 
the bed-covering, clothing, towels, toilet apparatus, and dressing 
or other materials which have been in contact with a diseased 
surface, should be immersed in boiling water before they are 
again employed for any use in common. Thin recommends 
covering every diseased patch, after the treatment appropriate to 
itself, with an adhesive and impermeable dressing, for the sake, 
not of the patient, hut of those with whom the latter may be 
brought into contact ; and the suggestion seems to me both 
wise and practicable. A gentleman infected with ringworm of 



TINEA VERSICOLOR. 531 

the beard in a barber's shop which he has visited but once, will 
often, when directed by his physician to shave, resort to some 
other establishment, where he is well known, and where he has 
more confidence in the cleanliness of the operators. In this 
way he often thoughtlessly spreads the disease of which he is 
the victim. In this ei-ty, I am in the habit of sending patients 
who cannot shave themselves to a particular barber, who being 
instructed in the manner of shaving so as not to communicate 
the disease, has thus far failed to originate a single case. 

Tinea Versicolor. 

Tinea versicolor is a cutaneous disease, occurring chiefly upon the trunk, neck, 
and upper extremities of adults, characterized by irregularly reticulated 
macular lesions, yellowish or brownish in hue, over which the epidermis 
may exfoliate in delicate scales, owing to the presence of the microsporon 
furfur. 

Symptomatology. — The eruption occurs in the form of few or 
many, irregular, roundish, circumscribed or reticulated maculae, 
pea- to small coin-sized, rarely occupying an area of the size of 
the palm or larger. In color, it varies from the most delicate 
buff or fawn shade to a reddish, deep brown, and even blackish 
hue. The surface of each lesion, when closely inspected, is 
usuall} 7 seen to be covered by furfuraceous scales. If the latter 
are not visible, slight erasion with the finger nail will demon- 
strate the fact that the superficial layers of the stratum corneum 
are, in the site of each lesion, readily separable from the tissues 
beneath. The eruption is most common upon the anterior sur- 
face of the thorax, but is also displayed upon the neck, the dor- 
sum, and the other surfaces of the trunk, and the flexor aspects of 
the upper extremities (the hands only excepted). It is rarely seen 
upon the lower extremities; still more rarely on the face ; never 
on the hands and feet. The eruption is either unproductive of 
an} 7 sensation, or accompanied by a mild pruritus. Patients 
will usually declare, that after profuse sweating, bathing in 
warm water, or brisk friction of the surface, minute epidermal 
rolls separate from the affected area. 

Exaggerated forms of the eruption are occasionally encoun- 
tered. In a young married woman presented to me, who had 
been the subject of the disease for many years, .the entire 
trunk, the axil las, groins, upper portion of the thighs, the 
neck to the level of the high collar worn, and the upper extremi- 
ties to the wrists, were encased in a uniform sheet or cuirass of 
chocolate-tinted epidermis, in a condition of exfoliation in finger 
nail-sized lamellated flakes. Even in these extreme cases, the 
tendency of the disease to avoid the surfaces exposed to the 
light is distinctly manifested. Unna 1 describes another anoma- 

1 Viertelj. f. Derm. u. Syph., 1880, Nos. 2 and 3. 



532 DISEASES OF THE SKI.V. 

Ions feature of the disease, in which the maculations occur in 
annular form with r clearing centre. Rarely, also, a very few 
irregularly distributed macula? may be seen as the sole evidences 
of the existence of the parasite. Tims a patient may exhibit a 
small coin-sized patch on the surface of the chest, another on 
the Bhoulder, and possibly a third over the deltoid region of one 
arm. These arc generally cases partially relieved of a more dif- 
fuse eruption. More commonly, the slightest manifestation of 
the malady is an irregular, vertically arranged, somewhat narrow 
band of lesions immediately over the sternum, and visible be- 
neath the hairs of that region in the adult male, or upon the 
intermammary sulcus of the female. 

Etiology. — The disease is produced by a vegetable mould dis- 
covered by Eichstedt in 1.846, to which Kobin gave the name, 
microsporon furfur. In capabilities for contagion, it is far in- 
ferior to the vegetable parasites already described, and illus- 
trates well a point to which attention has been already directed, 
viz . that all these fungi flourish only in soils suitable to their 
germination and fructification. Members of one family are said 
to communicate the disease occasionally, the one to the other ; 
and Lancereaux 1 reports that in this way he accidentally in- 
fected himself from scales collected for examination from a 
patient in hospital, and afterward unwittingly transmitted the 
affection to his wife. I have never had personal knowledge of 
any instance of such transmission. The disease occurs in both 
.-exes, rarely before puberty and after middle life, and in persons 
of every social condition, irrespective of personal cleanliness. It 
is exceedingly common, more so indeed than statistics are capable 
of demonstrating, inasmuch as hundreds are annually annoyed 
by it who never seek professional advice. In the thousands of 
physical examinations made by me with a view to the enlist- 
ment of men in the United States service during the late war, 
as also of many government pensioners since that date, I have 
been particularly impressed with this fact. Being concealed by 
the clothing and unproductive of much discomfort, many per- 
sons endure its presence with complacency. 

By some it has been supposed that the fungus is particularly 
apt to select the chest of the phthisical as its habitat, a suppo- 
sition doubtless based upon the fact that tuberculous men and 
women, more than all others, expose the chest to the view of the 
medical man in order to permit of its auscultation and per- 
cussion. 

Pathology. — The microsporon furfur is readily recognized by 
the aid of the microscope, as it exists in luxuriant profusion 
upon every affected surface. The scales may be scraped from 
the skin and at once examined, when innumerable clustered 
spores and short mycelia become visible; the former highly re- 

1 Tiailt- d'Analf mic Pathol., xi. p. 26.1, Paris, 1ST5. 



TINEA VERSICOLOR. 



53 3 



fractive and resembling in their circular and oval contours, drop- 
lets of oil. Their aggregation in clusters is distinctive of this 
among the other forms of cryptogamic vegetation. They measure 
.0023 to .0084 mm., while the mycelia vary in diameter from 
.0015 to .0038 (Duhring). Among the latter, sporophores are 
distinguishable, with contained conidia and terminal elements 
emerging at one extremity or the other of the spore-case. Both 
elements are more readily stained by eosine and methyl-violet 
than those of the trichophyton or of favus. 

Fig. 57. 




Microsporon furfur. (After Kaposi.) 



One of the strongest arguments against the claim for the 
identity of all the vegetable parasites, is furnished by the history 
of this interesting mould. It never by any possibility invades 
the hairs or the hair-follicles, though it may be seen flourishing 
at the orifice of a follicular duct, and even beneath a vigorous 
pilary growth upon the chest of a male subject. It avoids the 
light and the air; and singularly refuses to encroach upon cer- 
tain covered portions of the body, even preferring, in its ex- 
tremist development, to linger unobtrusively at the neck near 
the verge of the collar. 

Diagnosis — Here, as in all the parasitic diseases of vegetable 
origin, the microscope may be required to decide the diagnosis 
in any case where a doubt might arise. In its simpler manifes- 
tations, the recognition of the affection is very readily assured. 
The location of the eruption; its characteristic shades of color 



534 DISEASES OF THE SKIN. 

due to the nature of the fungus ; and, better than all, the exfo- 
liation of the epidermis which it ex--ites by its superficial ; 
tration of the outer layer of the stratum corneum, producing 
thus a mealy, branny, flaky, or roll like exuvium; all thi 
significant. None of the chloasmata due to pigment changes in 
the .-kin. however much they may resemble tinea versicolor in 
color, share with it this peculiarity of desquamation. Chloasma 
may involve, moreover, the face; tinea versicolor almost never. 
Vitiligo may occur upon the scalp; tinea versicolor never. The 
macular syphiloderm may be mistaken for the disease under 
consideration, but when developed to such an extent as to rival 
tinea versicolor in its diti'useness, the syphiloderm will creep 
out over the face, the hands, and the feet ; and will he accompa- 
nied by adenopathy, alopecia, mucous patches, palatine hypere- 
mia, or other evidences of a polymorphic tendency. Often, indeed, 
with such an eruption, the survival of the initial sclerosis will 
at once betray the nature of the disease. These are important 
considerations, since in the mere matter of subjective sensation, 
color, shape, and size of lesion, there may he marked resem- 
blance hetween the two. I have treated several patients with 
tinea versicolor who were suffering from syphilis; and many 
having the former disease who, from the fact of exposure, be- 
lieved they also were infected by the latter, and yet indeed were 
not. These incidents serve to illustrate the importance of making 
an accurate diagnosis in every case of cutaneous disease. 

The most vulgar error, however, committed in this connec- 
tion, is based upon the fancied resemblance in color hetween the 
patches of tinea versicolor, and either the liver itself or the 
color changes which disease of that viscus is capable of produc- 
ing in the skin. The existence of " liver-colored" spots on the 
skin, is hence erroneously attributed to hepatic disease. A re- 
markably comely, healthy-looking woman of high social stand- 
ing, once consulted me, who had been vainly treated for two 
years by internal remedies addressed to the liver, with a view to 
the removal of large patches of tinea versicolor from the bosom. 
She was completely relieved of her disfigurement in a single 
week by the employment of local measures alone. Few patients 
consult their physician for the relief of this disorder, who have 
not a prejudice of similar sort. 

Treatment. — I must admit that I have always employed but 
a Bingle method of relieving tinea versicolor, lor the simple rea- 
son that that one has been invariably successful. It is practically 
that given l>y Tilbury Fox. and requires merelj' vigorous and 
intelligent cooperation on the part of the patient. A hot bath 
is taken, if possible for three nights in succession, and when the 
surface is well macerated by the hot water, the affected skin is 
resolutely scrubbed, either with the cheap yellow soap of the 
grocer, or sapo viridis in substance or tincture. When the dis- 
ease is unusually developed, this process is aided by friction 



TINEA VERSICOLOR. 535 

with the flesh-brush or a coarse towel. The skin is then washed 
clean with a surplus of hot water, the patient still remaining in 
the bath, after which the affected patch is first moistened with 
vinegar and water, or dilute acetic acid, and afterward well 
sponged with a solution of the sodium hyposulphite, one drachm 
(4.) to the ounce (32.) being usually sufficient. As a rule, the last 
vestiges of the eruption are removed with the third bathing. 
Should there he recrudescence in isolated patches, as is often the 
c.ise, or outlying areas which have withstood the parasiticide 
employed, these should he subsequently attacked with a solution 
of the corrosive chloride of mercury, one to two grains (.066-.133) 
to the ounce (32.) Other measures, however, are popular with 
physicians, and among them may be named the topical use 
of boracic, carbolic, and sulphurous acids; the tincture of 
iodine; sulphur in bath, ointment, or lotion; calomel in oint- 
ment; the alkalies in baths or lotions; sulphide of potassium in 
bath ; and the other parasiticides employed in the treatment of 
ringworm of the body. The inner clothing should not be worn 
after treatment till it lias been immersed in boiling water. 

Prognosis. — The disease can be readily relieved by simple treat- 
ment. Relapses often occur, and require to be radically treated. 
Untreated, the disease may continue for years without the 
slightest impairment of the general health. It is probable that 
when untreated, the parasite undergoes spontaneous exfoliation 
in advanced years, a period when presumably the fungus fails to 
find in the epidermis the nutriment upon which it thrives. 

Myringoniycosis. 

The spores of the aspergillus, being conveyed to the external 
ear, occasionally develop there, especially if they come into con- 
tact with fatty substances introduced for medicinal purposes. 
Usually whitish masses can be recognized in the canal, covered 
with greenish, brownish, or blackish spots. There is usually 
some deafness, with a sensation of ringing in the ears, and at 
times a thin serous discharge from the external auditory meatus. 
Lowenberg 1 recommends the injection of dilute alcohol into the 
canal for the destruction of the mould. 

1 Gaz. Heb. d. Med. de Paris, 1880, 2me ser. xvii. p. 579. 



536 DISEASES OF THE SKIN. 

2. Of Animal Origin. 

Scabies. 

Derir. Lat. srabere, to scratch. 
Scabies is s contagions cutaneous affection, characterized chiefly by the forma- 
tion of the cuniculns, or furrow, produced by the acarus scabiei which is the 
cause of the disease, as also by the occurrence of several of the elementary 
lesions of the skin, accompanied by itching. 

Symptomatology. — Scabies is a disease of polymorphic character, 
which may be viewed as an artificial eczema or dermatitis, pro- 
duced by the invasion of the itch mite. According to the extent 
to which the skin is primarily invaded liy the parasite, or 
secondarily injured by the traumatism which follows severe 
scratching of its surface, will its objective symptoms differ. 

Prominent among; the hitter is the cuniculns, or aearian fur- 
row, an elongated gallery excavated in the epidermis by the 
female acarus soon after her impregnation by the male. The 
latter does not enter the skin, but is lodged beneath the crusts 
or other exuviae which gather upon its surface. This cuniculns 
or furrow, is a whitish or yellowish, slightly arciform, linear 
lesion, covered with dots or specks of blackish aspect, representing 
feces of the mite, with regular parallel borders. It terminates 
at the upper extremity, by a vesicle, pustule, or exfoliation of 
the surface at the site of an infundibuliform depression ; and at 
the deeper extremity, by a whitish and yellowish, shining and 
salient point, representing always the acarus. This is the most 
characteristic symptom of scabies. 

In consequence of the irritation produced by the insect as it 
traverses this furrow, all the symptoms of acute ami chronic 
eczema tire presented in the region invaded. These tire vesicles, 
pustules, small papules, hyperaemia of the skin upon which these 
rest, crusts formed by dried serum, pus and blood, excoriations, 
fissures, and, in cases of long standing, pigmentation of the skin 
where the disease has existed. These lesions may coexist, several 
appeariug at the same time upon the skin of an affected indi- 
vidual ; small vesicles and pustules, with perhaps a few short 
funiculi visible upon their summit; excoriations; larger and 
longer cuniculi interspersed between inflammatory papules; a 
tumid skin, evidently the seal of a mild grade of dermatitis ; 
and crusts here and there, beneath which male and young acari 
are ensconced. Such is the composite picture of a typical eruption 
in scabies. 

The regions of the hotly attacked by scabies are particularly 
characteristic of the disease. These are the hands and feet, 
especially the interdigital spaces; the female breast; the penis 



SCABIES. 587 

and scrotum of tlie male; and, in persons who are seated in the 
performance of manual labor, as, for example, shoemakers and 
tailors, the region of the buttocks. In general, portions of the 
body subjected to constant pressure by the clothing, as, for ex- 
ample, the regions pressed by the corset of the woman, and the 
waistband of the trowsers in man, are sites of predilection. In 
other cases, the disease is encountered in the axillae, groins, and, 
as a matter of rare exception, over the entire surface of the body. 

The itching of scabies is occasionally severe, and has in fact 
conferred upon the disease its familiar English title, " the itch." 
This sensation is usually worse at night, when the parasite is 
rendered active by the heat of the body in bed, retained by the 
bed-clothing. It differs somewhat in different cases, being at 
times the cause of but little complaint. There is nothing charac- 
teristic, however, in the occurrence of this sympton, as equally 
severe pruritus accompanies eczema unconnected with parasites. 

Several artificial forms even of this polymorphic affection, are 
occasionally noted. In children, the face may become diseased 
after contact with the breast of the mother, or the buttocks 
after contact with the flexor aspect of the nurse's arm. Large 
vesicles, and even rupioid bullae, may result from the irritation 
of their tender skins. Again, in subjects predisposed to eczema 
for any reasons, the invasion of the parasite in one region of the 
body, possibly a region of preference, may originate an eczema 
in another locality whither the parasite has not wandered. In 
other cases, the most exaggerated forms of eruption are seen, 
usually in persons of filthy habits who have long suffered from 
the malady. Thus extensive epidermal callosities form, filled 
with debris of dead parasites unable to find nutriment longer 
in the cornified rete ; or extensive greenish and blackish crusts 
cover colonies of acari which survive beneath them for genera- 
tions of their race. The nails in such extreme cases may be in- 
volved. The so-called scabies norvegica, or Norwegian itch, 
belongs without doubt to this class. As a rule, however, the 
disease does not advance to these severe grades. The parasites 
having gained lodgment in the skin, produce characteristic 
symptoms of the disease in the average of cases, but even though 
unrecognized, and persisting for weeks, are the sources of so much 
annoyance that treatment of some sort is instituted which is apt 
to restrict the extension of the malady, certainly in this country, 
within moderate limits. Usually after lodgment is effected, a 
week or fortnight elapses before the first characteristic furrow 
is formed, though the pruritus is of earlier occurrence. The ex- 
tension of the disease by the maturing and ravages of young 
acari requires a few weeks more, so that in the course of from 
two to three months, the evolution of the malady may be con 
sidered as complete. In the course of about three months more, 
the disease, unchecked, may become generalized. 

Even the animal parasites elect the soil upon which they 



538 DISEASES OF THE SKIN. 

thrive, and iudeed, after Buch electiou, thrive well or ill accord- 
ing to the conditions present. This is not only exemplified in 
the matter of individual susceptibility, but in the conditions of 
health of an affected person. Tims in puerperal and typhoid 
fevers and other grave states of systemic disturbance, the para- 
sites perish in the skin, and the resulting eruption disappears; 
classical symptoms recurring in convalescence if one or more 
acari have survived with sufficient vigor to reproduce their 
kind. 

Etiology. — The disease is produced only by the acarus scahiei 
(or sarcoptes scahiei) and is thus contagious, the parasite being 
introduced upon the surface of one individual, mediately or im- 
mediately from the skin of another infected man or an animal. 
All persons are supposed to be susceptible to the disease, but 
the difficulty of intentionally transmitting it by contagion, 
is greater than that of inducing the leech to fasten itself in- 
discriminately upon any given skin. The brief shaking of the 
hand or transient personal contacts of the daytime, are certainly 
in many cases quite insufficient for contagion. I have repeatedly 
handled the skin of a patient affected with scabies for half an 
hour at a time, always with impunity; and never happened to 
know of a student of medicine who suffered after the most care- 
ful examination of a dispensary patient. Yet scabies is becom- 
ing such a rarity in this city, that when a case is exhibited at 
the clinic, it is minutely examined by dozens of young men. It 
is probable that the contacts of the night, incidental to the occu- 
pation of the same bed, or the use of gloves and other articles 
of apparel containing parasites or their ova, is essential to the 
transmission of the disease. For it will be remembered that, as 
regards the parasite, it is absolutely requisite for such transmis- 
sion either that a fecundated female not yet entered her burrow, 
should find lodgment upon the skin ; or that parasites, young 
or old, of the two sexes, should be simultaneously transferred 
to it. These conditions would be easily tilled only by prolonged 
contact or contiguity between sound and diseased individuals, 
or by rare accident. 

The disease is indeed one peculiar to those classes whicli are 
the familiars of filth and poverty, occurring among these at all 
ages and in both sexes. As a matter of accident, it may appear, 
however rarely, in individuals of high social station. It is much 
more common in Scotland, Austria, Prussia, Sweden, Norway, 
France, and the Orient, than in this country. During the late 
civil war, it prevailed with relative frequency among the masses 
of A mericans associated in regiments with foreigners who had 
been but a short time in the country ; and since then, seems to 
have steadily decreased. But two or three cases are seen annually 
in the public clinics of this city, though here and there, chiefly 
among newly arrived immigrants, isolated " nests" of the disease 
are discovered. 



SCABIES. 



539 



Pathology. — The pathology of the eruption induced by the 
parasite is that of the various phases of exudation. The differ- 
ences betrayed between scabies and all other eruptions of similar 
type, depend, in the case of the former, upon the peculiarities of 
the exciting cause of the disease. In the description of this, the 
acarus scabiei, I shall avail myself of the admirable chapter de- 
voted to the subject by Kaposi. 

The female acarus, visible as a yellowish-white dot at the 
cul-de-sac of her subcutaneous gallery, and removed thence on 

Fig. 58. 








Female acarus, fecundated ; ventral surface. An ovum arrived at maturity is visible 
within the body. (After Kaposi.) 

the point of a fine needle, is visible to the naked eye, but best 
examined under the microscope. The body is oval, with a short 
projecting head and a convex dorsum transversely corrugated, 
with short spinous processes projecting for the most part back- 
ward, a direction largely followed also by the eight long bristles 
which are most noticeable at the posterior extremity of the 
trunk. The posterior portion of the dorsum also exhibits a 



540 



DISEASES OF THE SKIX 



series of re-curved, short, hook-like projections, arranged circle- 
wise, about the ano- vaginal orifice. 










:/ 






Aearian furrow, from the Lumbar region. The female acarua is visible at the terminal ex- 
(remit? of the furrow with ventral surface exposed, and containing a mature ovum ; two ova, 
next her, have heen laid during the day. as the third exhibits traces of the embryo; the 
twelfth exhibits a mature larva : twelve empty shells are also seen ; between these the feces are 
represented by blackish points. (After Kaposi.) 

The flat ventral surface exhibits eight short claws or legs, 
four anterior and four posterior. The former are set near the 



SCABIES. 541 

head, and are provided each with hairs, and a long, peduncu- 
lated sucker. The latter are armed solely with long, straight 
bristles. All the eight have five articulations. The head is oval 
in shape, and provided with four pairs of mandibles and six palpi. 
There are two ventral outlets; and a stomach, intestines, ova- 
ries, muscles, and even mature ova can be recognized internally. 

The males are smaller than the females and fewer in number. 
They differ also in this, that the posterior extremities are pro- 
vided with suckers and stalks, as are the anterior extremities of 
the female. Situated between these and in the median line, is a 
horse-shoe shaped mass of chitine ensheathing a fork-shaped 
penis. 

They are said to die in the course of from six to eight days 
after copulation with the female. The latter survive from 
twenty to sixty days. 

The female alone, as already said, penetrates the epidermis. 
This act she accomplishes by inserting the head first into the 
tissues of the skin, the body disappearing afterward, and de- 
positing behind, in the course of her progression downward, 
from one two eggs daily till from twenty to fifty have been laid. 
These are oval, their longitudinal axes placed transversely to 
the cuniculus. In the two or three eggs found nearest the 
female, only a yellowish color can be distinguished ; in the third 
to the fifth, traces of the embryo are recognizable; the sixth to 
the ninth contain larvae; and, in the oldest, the head and front 
legs can be discerned. There are six of these extremities when 
all are developed. When mature, the shell of the ovum is rup- 
tured, usually between the third and sixth day, and the young 
acarus leaches the surface of the skin, either by making exit at 
the original point of entry of the mother, or by rupture of the 
roof of the burrow. It subsequently buries itself in the skin 
for a brief time, while the process of casting its slough is com- 
pleted. There are said to be three of these periods in its exist- 
ence. Before the first is accomplished, the young acarus is pro- 
vided with but two pairs of posterior extremities, two anal 
bristles, and ten dorsal spines. After the first, it is an octopod 
with four oval bristles and twelve dorsal spines. At the second, 
it gains two dorsal spines ; and after the third it possesses four- 
teen. The acarus survives but a few days when removed from 
the skin and immersed in liquids which protect it from the air, 
such as water, oil, etc. 

The transmission of the acarus peculiar to the horse, cat, 
sheep, rabbit, elephant, etc., may be accomplished ; but the 
colony under these circumstances rarely thrives. The same is 
true of the human acarus transferred to the lower animals. 

Diagnosis. — The diagnosis of scabies must rest upon the recog- 
nition of its special features described above. There are no 
lesions peculiar to the disease save the cuniculi or furrows made 
by the parasite; and these, it will be remembered, do not appear 



542 DISEASES OF THE SKIN. 

till one to two weeks Lave elapsed after infection. They may 
;t)><> lie obliterated or concealed by excoriations when the finger- 
nails plough them open ; or by nustulation and subsequent crust- 
ing when the irritation induced is excessive. In every well- 
marked case, however, cunicnli can be discovered, if not on the 
lingers, wrists, or forearms, at least on the penis, the breast near 
the nipple, or some other covered portion of the body. With 
care and a little dexterity, a tine cambric needle can be then 
forced into the furrow well down to and a little beyond its 
remote cul-de sac, and the fons et <>r"j<> malorum be thence ex- 
tracted and placed under the objective of the microscope. 

Next to the cuuiculus, and its inmate or inmates, the two 
most important diagnostic features of scabies are, the polymor- 
phism <>f the eruption and the sites of its most frequent occur- 
rence. Possibly the latter should be named first, as the more 
important of the two Few skilled diagnosticians would fail 
to entertain a suspicion of scabies in a ease of supposititious 
"eczema,"* existing upon the fingers, wrists, and penis onl} r ; or 
on the breast of a mother, the face and buttocks of her infant, 
and the arms of its nurse. 

At the same time, it is a matter of great importance to remem- 
ber that eczema is often attended with very severe itching; that 
this sensation may be intensely aggravated after retiring to bed 
at night; is often limited to the hands; is not rarely character- 
ized by interdigital vesicles and pustules: and is, indeed, in this 
country very much the more frequently encountered of the two 
diseases. The vulgar conception of scabies holds to the belief 
that the disease is exceedingly common ; that every severe itch- 
ing with a cutaneous exanthem is produced by "insects" or 
•• worms'' in the skin ; and that transient casual contacts are 
abundantly capable of transmitting the offending parasite. Many 
more cases of simple eczema are supposed to he scabies than the 
reverse. There are few villages in the country which cannot lay 
claim to an " itch," often known by a name of local significance. 
Among these may he counted the so-called " prairie itch" of the 
West. These are, as a rule, forms of eczema quite unconnected 
with the existence of a parasite, and incurable generally by the 
parasiticides too often employed to " kill" the disease. In all such 
instances, the absence of the characteristic features of scabies 
described above, the absence of a history of contagion, and the 
presence of that of an alternating relief and aggravation of the 
symptoms, will point to the real character of the malady. 

Treatment. — The treatment of scabies has in view the destruc- 
tion of the parasite and the relief of the cutaneous disorder which 
the former lias induced. Ordinarily the two indications are ful- 
filled at the same time. In such cases, the destruction of the 
parasite is followed by relief of the resulting cutaneous lesions; 
and the skin, freed from the burrowing acari, is no longer tor- 
mented by the scratching which in extreme cases is not only 



SCABIES. 543 

irresistible but an important element in the aggravation of the 
lesions. In other eases, however, the resulting eczema or der- 
matitis persists after the removal of the original cause of the 
disease, and demands special attention. Care should always be 
had to avoid treating the delicate skin of the infant with the 
severer remedies efficacious upon the thicker integument of the 
adult. 

Sulphur in all its forms and in various combinations, has long 
held the highest esteem in the treatment of the disease. Other 
remedies, however, of acknowledged efficacy are employed with 
satisfactory results, most of them owing their usefulness to the 
strong odor which the} 7 emit. Among these may be named, . 
carbolic acid ; petroleum ; the oils of cloves, rosemary, and 
mint; tar; balsam of Peru and balsam of Tolu; sty rax ; sta- 
physagria ; Vleminckx's solution, heretofore described; and 
sapo viridis. 

Sulphur is commonly employed in the form of an ointment, 
one to two drachms (4.-8.) to the ounce (32.), firmly, thoroughly, 
and carefully rubbed, first into the affected patches, especially 
between the individual fingers (or toes), about the wrists, over 
the palm and dorsum of the hand, into the axillae, about the 
nipple, penis, buttocks, or other invaded parts; and finally over 
the cutaneous surface in general, the head alone excepted. If 
no severe eczematous complications exist, the inunction is well 
preceded by a warm soap, or soft soap and water bath. But in 
the event of such complication, the bath should be deferred as 
decidedly injurious in the inflame 1 condition of the skin. 

This first inunction is preferably performed at night, after 
which the patient retires to his bed enveloped in woollen under- 
clothing, or wrapped in a blanket. It is neither wise nor neces- 
sary to induce sudation by these measures, for the skin is best 
retained in simply a greasy condition, unmacerated by sweat. 
In England, it is customary to bathe on the ensuing morning, 
but it is preferable to defer the latter till the cure is complete, 
however disagreeable the condition of the integument may be 
to the sufferer. The sulphur inunctions are thus repeated for 
three successive nights, a thorough warm soap and water bath 
being finally employed for the purpose of cleanliness. The 
clothing meantime should be either thoroughly disinfected with 
sulphur, immersed in boiling water, or subjected, in a stove or 
furnace to a dry heat capable of destroying all acari and. ova 
which might adhere to it. 

In France, the routine treatment of scabies is always preceded 
by a thorough friction for twenty minutes with soft soap, special 
attention being as usual directed to the invaded areas. This 
is at once followed by a bath in warm water, during which the 
surface is also thoroughly scrubbed for from thirty minutes to 
an hour. Lastly, the parasiticide is well rubbed on for fifteen 
minutes, the patient redressed in the underclothing (disinfected 



544 



DISEASES OF THE SKIN". 



during the progress of the bathing) and the final cleansing of 
the skin with water is practised within twenty-tour hours. 

When a resulting eczema demands attention, it is to he 
treated in accordance with the general principles considered in 
tlie chapter devoted to that subject. In such case the dusting- 
powders, the oleated lime- water, the zinc, diachylon, and even 
more stimulating ointments, may he employed with advantage. 
Generally, after a vigorous course of external treatment with 
sulphur, the patient should he instructed to defer any further 
topical applications to the skin for a week or more, in order to 
test the efficaciousness of the method pursued. 

One of the following formulae may be substituted for the or- 
dinary sulphur ointment : — 



R. Sulphur, flor. 5\ij ; 

Potass subcarb. 5vj ; 

Adipis 3' xxv ; 

Hardy's modification of llclmericli's ointment. 



11. 



Styracis. liq. 
Petrolei f 
01. olivse S 
Balsam. Peru v. 
Spts. sapon. virid. 

Potass, snlphuret. 
Sapon. alb. 
01. oliv. 
01. thym. 

Sulphur, sublim. 
Balsam. Peruv. 
xVdipis 



f3j; 

aa fgss 

i'3ijss 
i'3v: 



3v ; 
5xx; 
t'3iv ; 

gtts. xv ; 



aa 5 SS 



oO 
300 



For use especially in the scabies of children. 



M. 
(Kaposi.) 

20 
80 
14 

1 M. 

(Jadelot ) 

i m. 

32l 

(Duhring. ) 



Prognosis. — Scabies is an entirely curable disease, even after 
persistence for long periods of time. When, however, compli- 
cations exist, or severe eczema continues after the efficient ac- 
tion of a parasiticide, the patient may experience some delay 
before attaining complete restoration to health. 



Demodex Folliculorum. 

This parasite, known also as the steatozoon, or acarus, follicu- 
lorum, was discovered by Simon, in 1842. It is a microscopic 
creature in the form of an elongated and jointed worm, with 
head separated from the thorax, and eight legs, four on a side, 
each with three articulations, and terminating in three small 
booklets. The posterior extremity of the body is a vermiform 
appendage, terminating in a conical point. 

The demodex is found upon the free surface of the skin, those 
parts particularly where the sebaceous glands are large, and on 
patients affected with acne or seborrhcea oleosa, as well as upon 
those free from all evidence of disease. It is encountered also 



SCABIES. 



545 



in the substance of the comedo plug, where at times from five 
to twenty may be discovered in a single follicle. It is, however, 
in no case the source of disease. A demodex, which is consid- 
ered to be a variety of that discovered upon 
the skin of man, infests dogs, mice, and other Fig. 60. 

of the lower animals ; and may be, in the latter, 
the source of disease characterized by furun- 
cular lesions, abscess, and even fatal results. 
None of these parasites are, however, known 
to be transmissible to man. 



Pulex Penetrans (Rhinocoprion Penetrans). 

The sand-flea is a minute parasite which 
penetrates the skin of man and of the lower 
animals, including rats and mice. It is en- 
countered chiefly in tropical countries, but is 
said also to exist in higher latitudes, even in 
some of the southern of the United States. 
Fecundated females only attack the skin, in 
man usually about the toes or near the nails, 
entrance being effected with scarcely painful 
pricking sensations. In the course of from ten 
to five days, a painful oedema with pustulation 
follows, occasionally accompanied by a lymphangitis or severer 
symptoms in the form of gangrenous abscesses. These sequelse 
are said to result from the distension of the ovary of the para- 
site, which may exceed fivefold the original dimensions of the 
insect. The treatment of the disease is the extraction of the 
flea by the aid of a heated needle, whereby it is simultaneously 
destroyed. The resulting wound is often also cauterized. 



Demodex folliculorum. 



Filaria Medinensis (Filaria Sanguinis, Guinea Worm). 

This parasite is encountered in the tissues only of those who 
have resided in tropical latitudes, more particularly in Egypt, 
Persia, India, and Arabia. It is occasionally encountered in 
other countries after introduction by affected individuals. When 
it attacks the skin, it forms a painful, ceclematous, furuncular or 
bullous lesion, which bursts; and in the fluid contents exuded, 
a portion of the worm becomes visible. Often the systemic con- 
ditions which accompany this lesion are grave. Febrile, con- 
vulsive, or septicemic phenomena may then be followed by 
fistulous or gangrenous results in the seat of the disease. 

It was long claimed that the parasite entered the skin from 
without, but there is reason to disbelieve this assertion. Ob- 
servers have lately demonstrated the fact that the parent worm 
contains, in that part of the body which is appended to the 
head, thousands of minute worms contained in a sarcodiform 
envelope. These measure 0.05 by 0.02 mm., each exhibiting a 
35 



540 DISEASES OF THE SKIN*. 

thickened cephalic extremity without a buccal aperture, and a 
pointed caudal termination. It is impossible for such a creature 
to penetrate the skin lry the accidents usually assigned as the 
occasion of its introduction; for example, bathing in infected 
water, and walking upon surfaces where the parasites abound. 
It is much more reasonable to conclude that the latter are in- 
gested, either with the food, or, more probably, with the water, 
and that from the alimentary canal they find their way to the 
other structures which they attack. They can certainly traverse 
the blood -vascular channels. My colleague. Dr. W. T. Belfield, 
of this city, has photographed the worm in situ, in the blood- 
vessels where it was discovered. It is possible, however, that 
the parasites may be, in rare instances, introduced into the skin 
directly through solutions of continuity produced in walking, 
bathing, and other occupations, when the foot or ankle is acci- 
dentally abraded, or where indeed there has been a pre-existing 
ulcer or sore. Manson 1 believes that the parent filaria inhabits 
the lymphatic trunks; and reports a case of lymph scrotum in 
which a long slender worm, resembling catgut in appearance, 
and of the thickness of a medium-sized horse-hair, was found 
filled with embryos in different stages of development. After 
the removal of about two inches of the parasite, the worm was 
broken. It has also been recognized in the sac of the tunica 
vaginalis affected with hydrocele. 

The mosquito is said to act as a carrier; sucking the filaria 
with the blood of an affected person, it afterwards deposits the 
ova or embryos, which have meantime hatched, in the water 
where it lays its own eggs. These embryos are then swallowed 
with the drinking-water by another victim ; and so the circle of 
disease is completed. It is a nocturnal parasite. During the 
day the iilarige lie dormant at some point in the victim's circu- 
lation, but at night they sally forth and rove the current of the 
blood the night long. 

The parent worm, fully developed, may measure two feet, or 
more in length; and, being usually packed full of young, it is a 
matter of great importance not to injure it in any efforts made 
for the purpose of its extraction. Forbes Dick 2 describes the 
four methods chiefly employed for the purpose of obtaining 
relief, as operating on the principle, either to "stink, coax, suck, 
or pull the worm out." The first is usually accomplished by 
the aid of assafoetida poultices, and is the least desirable of all. 
A combination of the others is preferred, the warmth, moisture, 
and protection afforded by the poultice first attracting the worm 
to the surface. When this result is obtained, an incision is 
made, and usually a foot or more of the worm is at once liberated. 
According to Dick, when the worm can be felt at two or more 
places, the point for incision is at the third part of its anterior 

' Lancet, 1880, p. 10. 2 Brit. Med. Jour. 1880, p. 207. 



SCABIES. 547 

extremity, which is always furthest from the heart of the pa- 
tient. After this the worm is carefully wound about an aneur- 
ismal needle or similar implement, and. traction very gently made 
upon it for from ten to fifteen hours. If it cease to yield to 
this force, the traction should never be increased, lest the para- 
site seize the adjacent tissues with its mouth. Suction by the 
natives is accomplished through trumpet-shaped tubes. 

Cysticercus Cellulosse. 

Cysticerci have been recognized in the skin and subcutaneous 
tissues by Lewin, Guttmann, Schiff, Ferreol, Du^uet, and other 
observers. In such cases, one or several roundish, cutaneous or 
subcutaneous tumors, isolated or disseminated, unproductive of 
pain, and varying in size from that of the pea to the nut, project 
from the general level, and are enveloped by an unaltered integu- 
ment. They may remain in this condition without change for 
years ; and may accompany cj^sticerci of the brain and other por- 
tions of the body, productive of the serious disturbanceof the econ- 
omy which such invasion ma}- determine. If the skin tumors be 
opened and their contents examined, the parasite will be recog- 
nized as an ampulliform sac, with a cephalic appendage, reentrant 
or projecting, and provided with four suckers and a coronal of 
hooklets. By no external characteristics could such tumors be 
distinguished from others of similar size and external appearance. 
Only in the rare case of nervous complication, could a suspicion 
arise based upon the real character of the disorder. Respecting 
this matter, however, the diagnostician is in no worse position 
than when called upon to recognize cysticerci of the viscera. 
On more than one occasion, cysticerci of the liver have been dis- 
tinguished during life, and subsequently removed by operative 
procedures. 

Leptus. 

This is a minute, reddish or yellowish-red insect, visible to 
the naked eye, and found in summer and autumn clinging to 
bushes and grasses. It is found both in this country and in 
Europe. It attacks man only after its accidental location upon 
the skin, where it perishes in the course of a few hours. In 
such situations, however, it induces considerable irritation, be- 
trayed in erythematous, urticarial, papular, and even eczematous 
symptoms, accompanied by pruritus of various grades. It may 
be seen in the skin as an orange-reddish or brick-reddish point, 
which represents often the body of the insect, its head being 
buried in the aperture of a follicle beneath. Examined after 
extraction, it is seen to have a relatively large cephalic extremity 
and a well rounded body provided with six long legs. It is 
found upon the lower limbs particularly, but also upon the sculp 



.4s 



DISEASES OF THE SKIN" 



and every other part of the body. According to Duhring, chil- 
dren are particularly liable to its encroachments. The disorder 
is relieved by the application of a little balsam of Peru in olive 
oil. carbolated oil, spirit of camphor, or other mild stimulant or 
parasiticide. 

Dipterous Larvae in and beneath the Human Skin. 

There is no dipterous insect peculiar to man alone, but a num- 
ber of cases are on record where the ova of several species of 
oestrus have been deposited in the skin, and larva 1 been subse- 
quently formed. The oestrus bovis, or gad fly, is the most com- 
mon of these. Usually after the ova are deposited by the insect, 
a painful swelling occurs which may change its place from one 
point to another. When suppuration is induced, the larvae can 
he removed by pressure upon the boil. Walter Smith, 1 of Dub- 
lin, has lately described such a case, where the swelling upon the 
ankle of a twelve-years-old girl moved to the elbow, and there 
discharged a white grub nearly an inch in length. Birdsall 2 
has described a specimen sent him from Gaboon, on the West 



Fig. 61. 



mmm 



c d 

(Estrus. a, the larva, natural size ; h, 
some of the segments seen under a lens, 
and showing the lines of minute projec- 
tion ; c, and d, the terminal enda of the 
insect. (After Abraham.; 



Fig. 63. 




tus. (After Kiichenraeister.J 



Coast of Africa, in which two worms escaped from between the 
middle and the ring fingers of (me hand; another workman 
having had a similar accident occur upon the leg. The fly 
whose ova had been deposited in these two cases, was said to 
attack the* gorilla; and the Pawnees, a tribe of Indians engaged 
in capturing these animals, were reported as being very com- 
monly troubled in the same way. The worms sent to Dr. Bird- 
sail were respectively one-fourth and one-half of an inch in 
length, and about one-eighth of an inch in thickness. 



1 Sec Report of [nternat. Med. Congress, Arch, of Derm., Jan. 1882. 

2 N. Y. Med. Record, .Mar. 18, 1883, p. 298. 



PEDICULOSIS. 549 

Abraham, of Dublin, has also examined and reported upon a 
similar case, the specimen having been sent to the editor of the 
London Medical Press and Circular, from Portsalon, Letter- 
ken ny. 1 

Ixodes (Wood-Tick). 

Several species of ticks are recognized, such as the Ixodes 

HUMANUS, IXODES BOVIS (cattle-tick), IXODES AMERICANUS, IXODES 
MARGINATUS, IXODES UNIPUNCTATUS, and the IXODES RICINUS, the 

last named being more common in Europe. In this country 
they are found in wooded districts, especially those where pine 
and fir trees are growing. The female attacks the skin by 
thrusting into it her beak, armed on either side with a maxillo- 
labial projection having recurved hooklets, the mandibles also 
presenting similar obstacles to the forcible extraction of the 
head. After suction of the blood from beneath, the body of the 
tick swells to the size of a pea or small bean, and may remain 
for several days in this position. At such times the parasite 
may be mistaken for a small pedunculated tumor. Forcible 
attempts at extraction of the intruder are liable to detach the 
mandibles from the body, and thus leave them as the source of 
future irritation, and even disagreeable inflammatory symp-' 
toms, in the site of the punctured wound. By applying over it 
a drop of the spirit of turpentine or benzine, the head is spon- 
taneously retracted, and the body falls from its position. The 
soldiers on the plains of our own country, accomplish the same 
end with the juice of tobacco. The sensation produced at the 
moment of the insertion of the beak of the insect, is said to be 
so trifling as often to pass unnoticed. 

Pediculosis. 

Derzv. Lat. pediculus, a little foot. 
Pediculosis is a contagious affection, induced by the presence of lice upon the 
skin and hairs, by the wounds inflicted by the parasites, and by the scratching 
which the resulting pruritus excites. 

Symptomatology. — Lice belong to the order, rhynchotta; subdi- 
vision, parasites ; family ^edicalidw,. They are apterous, provided 
each with two eyes, and have an oral appendage capable of both 
inflicting wounds and. producing suction. Those infesting the 
human bcxty are recognized as belonging to three species, those 
of the head, of the body, and of the pubes. Of the disorders to 
which they give rise it may be said in general, that the lesions 
presented differ somewhat according to the region invaded, the 
multiplicity of the intruders, and the length of time during 
which their ravages have been inflicted. Such lesions, however, 

1 See that Journal for April 12, 1882, p. 314. 



550 DISEASES OF THE SKIN. 

are those which have been already studied in connection with 
eczema, urticaria, and the similar disorders resulting from exter- 
nal irritation. Their special peculiarities in pcdiculosis,are owing 
Bolely to the nature of the exciting cause and the mode of its 

operation. 

Pediculosis Capitis (Parasite, the Head Louse). 

The head louse is usually of a grayish color, hut differs slightly 
with the hue of the hairs over the part which it frequents. Its 
head presents indistinctly the outline of a trefoil, and is provided 
with two hairy antennae, each of five articulations, and two 
eyes. Its thorax is relatively narrow, with six tracheal stigmata 
and three hairy legs on either side, the latter provided with 
tarsal hooklets. The abdomen is divided into seven segments, 
defined by blackish indentations on either side. The males are 
fewer and smaller than the females, and present upon the dor- 
sum an ano-genital orifice and a large conoidal penis and testes. 
The females are provided with ovaries, oviducts which terminate 
in a vagina having a ventral orifice, and an anal aperture in the 
terminal abdominal segment. Coupling is performed with the 
male beneath. 

The ova or "nits" are whitish bodies of oval contour, which 
are glued to the hairs by the aid of a cylindriform sheath of chi- 
tine, which completely encases the cir- 
cumference of each filament. They are 
deposited in series, as the female tra- 
verses the hair from its insertion to its 
distal extremity, so that the oldest are 
in general the nearest to the scalp. The 
young escape from the ova in from three 
to eight days, and arrive at maturity in 
from eighteen to twenty days. A single 
female can, according to Kaposi, lay fifty 
eggs in six days, and thus in eight weeks 
have an entire progeny of 5000 lice. 
Head lice usually limit their habitat 

Pediculns capitis— male. (After ij.ii 1 11 i 

Kuchenmeister.) to the scalp, though, rarely, in elderly 

males with long hair reaching to a full 
beard, they may encroach upon the latter. They are found upon 
every portion of the scalp, hut find the region of greatest pro- 
tection upon the occiput. They infest children and adults of 
both sexes, but are best furnished with lodgment in the scalps 
of girls and women covered by long and luxuriant hairs. 

The lesions observe. 1 upon a scalji thus inhabited, vary accord- 
ing to the age and vigor of the colony ; and are few or numer- 
ous, discrete or confluent pustules, bullae, surfaces excoriated by 
scratching and oozing with serum, pus, or blood ; crusts varying 
in character according to the nature of the desiccated exudate 




PEDICULOSIS. 



551 



Fi< 






and sebaceous matters. Often the picture presented is a con- 
glomerate of an artificial eczema and seborrhcea. 

The ova, or " nits," are usually abundant upon the hairs of 
an infested head, and will scarcely escape the attention of a close 
observer. They are not to be mis- 
taken for the exfoliated, epithelial, 
and fatty plates seen in seborrhcea 
sicca, disseminated among the hairs, 
and often perforated by hairy fila- 
ments, since the former are firmljr 
glued in position, and resist the 
bristles of the hair-brush. The pe- 
culiarly nauseating odor also of the 
louse- infected, pustule- and crust- 
covered scalp, is not to be confounded 
with that perceived in f'avus of the 
same region. 

In exaggerated cases, the post- 
cervical ganglia express by their 
increase in size, the degree to which 
the local irritation has been pushed. 
The itching is usually severe, and, 
in cases of long persistence in chil- 
dren, may produce the usual syste- 
mic symptoms of prolonged local 
irritation. Children and others of 
impoverished health and with poor 
hygienic surroundings, are thought 
to exhibit the disease in severer 
grades than others; but this, if in- 
deed a fact, must be at least in part 
due rather to the more favorable 
conditions for the development and 
multiplication of the parasites, which 
are presented in filth accumulation 
and lack of cleanliness. At the Infirmary of the Chicago Home 
for the Friendless, children are presented every week affected 
with pediculosis capitis, who come from the very lowest social 
grades of our population and from the filthiest quarters. Among 
these it has not been observed by me that the general health of 
the patients was a factor of weight in the severity of the affec- 
tion. 

The diagnosis of pediculosis capitis is a matter of consider- 
able importance, however simple of accomplishment, since many 
cases of supposed " pustular eczema of the scalp" have been 
treated vainly by one physician with internal remedies addressed 
to the sj'stemic vice assumed to be responsible for the disease 
which another has relieved after the discovery of a few head- 
lice. The hairs should always be raised and separated, the scalp 



m 



Ova of head-louse attached to hair. 
(After Kaposi.) 



552 DISEASES OF THE SKIN. 

ally inspected, and the presence of any parasites, anrl espe- 
cially <»va or •• nits"' fastened to the hairs, ascertained. Whether 
the lice have preceded or followed the eczematous state (and 
each of these conditions may be noted) is a matter of minor 
importance. 

The indications in the treatment of pediculosis capitis are the 
destruction of all parasites with their ova, and tire relief of the 
induced inflammatory condition of the scalp. Generally, the 
removal of the former is followed by the spontaneous disappear- 
ance of the latter. 

For the destruction of the lice, the most popular remedy, in 
this country certainly, is petroleum, poured over the scalp in 
quantity sufficient to cover it without overflow upon the brow, 
temple8,and neck. Tt should he rubbed in with a piece of white 
(undyed) flannel. At the end of from twelve to twenty-four 
hours the lice arc destroyed, and the ova rendered incapable of 
development. This treatment is followed byathorough shampoo 
with tincture of soap or toilet soap and hot water; after this 
operation the tender scalp may require a bland unguent, such 
as vaseline or a small quantity of scented castor oil, either pure 
or in combination with spirits of wine. Kaposi employs petro- 
leum as a parasiticide in combination with olive oil and balsam 
of Pei u ; live parts of the first ; two and a half of the second ; 
and one of the third. Cutting the hair of women and girls is 
quite unnecessary, as patience and gentleness with the use of the 
comb will finally disentangle the most matted masses after the 
liee have been destroyed. Other remedies are employed locally 
for a similar purpose, of which the most popular are staphysa- 
gria. especially in decoction; carbolic acid in oil or water ; saba- 
dilla; the ethereal oils; and mercurials in ointment and solu- 
tion, including the mercuric oleates. In cases where but a few 
parasites have found their way to the scalp, and that recentl}', 
nothing more is requisite than a careful use of the fine-toothed 
comb, scrubbing the scalp with a strongly scented alcoholic per- 
fume, ami a final bathing with soap and hot water. 

The ova adhering firmly to the hairs can be removed by alco- 
holic solutions or dilute acetic acid, both of which are solvents 
for the gluey material by which the " nits" are secured iu [dace. 

Pediculosis Corporis (Parasite, the Body Louse). 

The parasite in this disorder inhabits exclusively the clothing 
worn next the body, and is hence properly designated as the 
PEDICULUS VESTIMBNTL In anatomical peculiarities it resembles 
the pediculus capitis already described, being, however, larger 
in size, the females also larger than the males. The eyes are 
black and very prominent in both sexes; ami the periods requi- 
site for the maturing of the ova and young are those named 
respectively in connection with head lice. In color they vary 



PEP1CULOSIS. 



553 




Pediculus vestiiuenti — female. 
(After Kiichenmeister.) 



slightly from a dirty-white to a light grayish hue, when un- 
distended with blood. In the reverse of this last-named con- 
dition, they may be recognized as having 
a dull reddish or purplish color when 
they are also more indolent in their 
movements. 

They inhabit the seams of undergar- 
ments where their ova also are deposited, 
but in coarse woollen or flannel shirts 
find sufficient shelter in the meshes of 
the material of which the clothing is 
made. This they leave temporarily, 
solely for the purpose of obtaining nutri- 
ment from the skin of their host, and 
hence are not often recognized upon the 
free surface of the integument. Upon 
rapid removal of the clothing of an in- 
fested individual, a few may occasionally 
he encountered, hastily seeking a place 
of refuge, though this is rather the ex- 
ception to the rule. It thus may happen that a louse-bitten 
patient may not exhibit the true source of his troubles to his 
physician after a recent and complete change of clothing. The 
greater then the importance of being able to recognize the clin- 
ical features of the malady in the absence of the parasite. This 
is comparatively easy to one who has made himself familiar 
with the symptoms of the disorder. 

The maimer in which the louse is enabled to supply itself 
with the blood of man has been carefully studied by Swammer- 
dam, Landois, Schjodte, and Tilbury Fox. The last-named au- 
thor has summarized the observations of the others, and the 
results he gives may be briefly described as follows : — 

Swammerdam's original view that the louse is not provided 
with mandibles by which it can inflict a wound, but with an 
haustellum by which the blood is sucked up to the head of the 
parasite, is confirmed by Schjodte. This observer, examining 
the head of the louse from behind with reflected light, discov- 
ered that the parts of the head resembling mandibles in appear- 
ance, were really situated beneath its skin. He applied to the 
integument lice which had been previously starved, and watched 
each as with retracted limbs, arched back, and head inclined 
obliquely downward, it repeatedly projected forward and re- 
tracted through the extreme end of its head a " small, dark, 
narrow organ," by which it was finally firmly held in place. 
A triangular blood-red point soon became visible in front of the 
eyes, rapidly and alternately contracting and dilating, and fol- 
lowed by energetic peristalsis of the gastro-intestiual tract. If 
the head then be cut off in front of the eye*, and the haustellum 
carefully extracted, the latter can be recognized as a brownish 



554 DISEASES OF THE SKIX. 

protrusion, armed with terminal recurved hooks, from which 
depends ;i delicate membranous tube varying in length. 

" It seems that the mouth is like that in the rhynchotta gene- 
rally, but ditt'ers in the circumstance that the labium is capable 
of being retracted into the upper part of the head, and lias a 
fold in it when so retracted. In order to strengthen this part, 
a flat hand of chitine is place:! on the under surface; and it is 
thinner in the middle in order that it may bend and told a little 
when the skin is not extended by the lower lip. The latter 
(.•(insists of two hard lateral pieces, of which the fore ends are 
united by a membrane, so that they form a tube, of which the 
internal covering is a continuation of the elastic membrane on 
the top of the head. Inside its orifice are a number of small 
hooks, which assume different positions according to the degree 
of the protrusion ; and if this is pushed to its highest point, 
they form a collar of hooks curved backward like barbs. The 
pediculus first inserts its labium into a sweat pore and protrudes 
the lip. When the hooks get hold of the parts around, then 
the first pair of setae (the real mandibles transformed) are pro- 
truded, and these are toward the point invested by membrane 
so as to form a closed tube, from which again is exserted a 
second pair of setae or maxillae, which form a tube and end in 
four small lobes placed crosswise. The whole forms a mem- 
branous tube, along the walls of which retiform mandibles and. 
maxillae are placed as long narrow bands of chitine. This tube 
can be lengthened or shortened at pleasure." 

This explanation of the mode in which the louse attacks the 
skin, is probably true of each of the varieties which infest the 
human body. Fox well suggests that the invaded follicle, after 
the withdrawal of the haustellum, becomes the seat of a circum- 
scribed hemorrhage. None of the anatomical peculiarities de- 
scribed above will, however, completely explain, it seems to me, 
the characteristic pruritus of pediculosis corporis, for it can 
scarcely be questioned that it is not merely at the moment of 
attack or penetration that the suffering of the victim is great- 
est. The pruritic condition of the louse-wound persists, indeed 
usually attains its maximum, after the withdrawal of the pedic- 
ulus, and is without doubt greater than that awakened by 
merely mechanical puncture of the epidermis. Any one who 
will compare the skin of a louse-infected patient with one who 
has been subjected to the acupuncture process employed among 
the lower classes of Germans, and by them known as " baun- 
seheidtistnus," can convince himself of this fact. 

The lesions seen on the skin thus invaded are proportioned, 
as in pediculosis capitis, to the size and age of the colony of 
parasites. Excoriations, usually linear, occasionally circum- 
scribed, varying in depth and length, radiate irregularly from 
each louse wound, and may be commingled with minute pap- 
ules, transitory wheals, or, in rare, exaggerated cases, with the 



PEDICULOSIS. 555 

typical signs of diffuse eczema. All are produced by scratching 
in order to relieve the pruritus. Crusts, more often composed 
of desiccated blood, rarely .of serum or pus, minute and capping 
the wounded follicle, or linear and coextensive with the exco- 
riations produced by the scratching, are generally conspicuous. 
In older cases these lesions are followed by the usual sequela, 
pigmentation, the latter being a partial indication of lousiness 
which has been long tolerated. 

In this country, it is rare to note the severe and intense forms 
of the malady resulting from long continued neglect of the skin, 
which occur in Germany. In such cases, dermatitis, rupioid 
crusts, furuncles, abscesses, carbuncles, and ulcers form, bequeath- 
ing to the skin serious disorders, which may persist for weeks after 
the clothing has been freed from lice, and finally leaving deep- 
tinted, diffuse pigmentation of the surface, suggesting that of 
the negro or of the patient affected with Addison's disease. 

The diagnosis is a matter of importance. Patients will visit 
physicians, claiming that they have suffered from a "humor of 
the blood," who have been swallowing drugs for a long period 
of time, in the vain hope of obtaining relief, with lice, at the 
very moment of uttering the complaint, crawling over their 
persons. Even those of good social position and habits of clean- 
liness, will occasionally suffer after the accidental contacts in 
the street- or railway-car, the hotel, the theatre, or other places 
of public resort. There are certain points to be carefully noted 
in this connection. Excoriations over the nucha, about the 
shoulders, loins, buttocks, and external faces of the thighs, all 
visible at the same time, are highly suspicious symptoms; as an 
eczema, when equally diffuse, is sure to be accompanied at some 
point by perfectly classical features ; and generalized pruritus is 
exceedingly rare, its localized varieties concerning chiefly the 
regions about the mucous outlets of the body. There is a cer- 
tain facies highly suggestive of pediculosis when the exposed 
trunk of an infested patient is viewed from behind. The lesions 
are more discrete, more irregularly distributed, and more inter- 
mingled with long scratch-marks, reaching, for example, quite 
over the point of one shoulder, than in most disorders with 
which this could be confounded. Here and there minute blood 
specks tell a significant tale. I have occasionally the opportunity 
to exhibit patientsat the clinic, with syphilodermata interspersed 
among characteristic lesions of pediculosis corporis ; and often the 
students themselves in such cases point out the particular symp- 
toms referable to the separate disorders present. 

In private practice it is usually advisable, for obvious reasons, 
to secure the corpus delicti before informing the sufferer of the 
nature of his or her complaint. In the case of male patients, it 
is well to take a position in the rear, and when the under- 
clothing is drawn weli up from the shoulders, a careful scrutiny 



556 DISK ASKS OF THE SKIN'. 

of it may be made while the applicant for relief supposes that 
attention is directed instead to his person. 

The treatment of the disorder concerns largely the clothing. 
The latter requires immersion in boiling water, or may be 
wrapped in paper and subjected to a high temperature in an 
oven, 160 -175° F.. sufficient to destroy the lice and their ova. 
In case of recurrence of the malady, the clothing is to be sub- 
1 to the same process. Usually the resulting irritation of the 
skin promptly subsides. When several members of one family 
suffer, all clothing worn must be subjected to similar treatment. 
If the skin has been unusually tormented by the scratching, 
warm alkaline baths will afford some comfort, and may be fol- 
lowed by a bland unguent or one of the dusting powders. For 
immediate use, before the clothing can he rid of the intruders, 
a parasiticide ointment can he ordered as recommended by 
Duhring, prepared by adding two drachms (8.) of freshly pow- 
dered Btaphysagria to the ounce (32.) of hot lard, strained and 
cooled. The surface of the skin may also he anointed with car- 
bolic acid dissolved jn oil or water. 

Pediculosis Pubis (Parasite, the Pubic Louse). 

In this disorder the genital region is chiefly involved, though 
in exceptional cases all the hairy portions of the skin may be 
invaded, including the eyebrows, eyelashes, axilla?, and the 
moustache, heard, hairy chest, and hairy legs of the male. The 
body of the pubic louse is smaller than either of those described 
above. Its head is also attached more closely to its thorax, 
having a shape which is compared to that of a violin. The 
thorax is not distinctly separated from the abdomen : and of the 
six stout legs which spring from it, the second and third pair 
are conspicuously powerful, and armed with relatively large 
hooks at the tarsal extremity. The resemblance of the latter to 
Ihe claws of a crab, has given to this creature the common name 
of "crab-louse." The lateral abdominal indentations are much 
less distinct than in the other varieties; and the blackish mar- 
ginal markings of the latter are here scarcely apparent. The 
abdomen is also much less elongated, having a more rounded 
contour, and being provided on its lateral borders with eight 
short conical feet, terminating in bristles. It. is also distin- 
guished from the others of its family by the length of its anal 
bristles, and by the peculiar shield-shaped carapace which covers 
nearly one-half of the dorsum. 

The pubic louse is much more inactive than the others, and 
docs not ordinarily escape its pursuer. It buries its head deeply 
in a follicular orifice, and steadies itself in this position, where 
it may remain for some time, by grasping the adjacent hairs 
with its short, and powerful claws. A moderate degree of force 
isrequired for its dislodgment from this favorite position, and 



PEDICULOSIS. 



557 




Pediculus pubus. (After Schmarda.) 



when removed its grasp of the hair to which it clings is so firm, 
that the latter usually slides for its entire length through the 
claw of the louse. Occasionally they may be found creeping over 
the skin or clinging to hairs at a distance from the surface. 
The ova are smaller than those of 
the head louse, though having a 
similar color; and are, like the latter, 
attached to the hairs by a firm cbiti- 
iio us glue. 

Pubic lice are usually acquired 
during the contacts incidental to the 
sexual act; and are hence more fre- 
quently encountered among adults, 
but may, without any question, be, 
more rarely, transmitted mediately 
by occupation of beds and covering 
which have been used by infested 
persons. They are thus, though very 
rarely, found in children of both 
sexes. 

The lesions induced are those pro- 
duced by the wounds inflicted by the parasites and by consequent 
scratching, though the latter is rarely intense. In a few cases, 
I have seen a severe eczema follow the ravages of the lice, but 
in each case, I believe, the latter was chiefly owing to unneces- 
sarily severe self- treatment of the disorder, patients being often 
morbidly anxious in their efforts to rid themselves of the pests. 

The diagnosis of pediculosis puhis is between eczema and 
pruritus genitalium. The disease last named is, in both sexes, 
accompanied by itching and that often of intense grade, but 
when this is diffuse and symmetrical in distribution, it is not 
limited particularly to the hairy parts. Eczema of the genitals 
is not often produced by parasites of that region, and may be 
readily recognized by its characteristic features. Both disorders 
are often indeed limited to asymmetrical patches upon the side 
of the scrotum or one labium. The discovery of the parasite, 
however, in pediculosis pubis, is always essential, and requires 
merely careful inspection and a good light. The lice may be 
recognized either at or near the point of implantation of the 
hairs, which latter also display ova except in very recently 
infested individuals. The reddish excrement of the parasites 
mingled with scratch-marks and excoriated papules of small size, 
may also be observed. Patients are often made aware of their 
condition by a sensation of crawling over the parts. Scratching 
of the pubic region in adults of both sexes, should always awaken 
some suspicion of the disorder. 

The disease is commonly treated by the topical application 
of mercurial ointment, which is a disagreeable and rather filthy 
medicament for this locality. The ten per cent, oleate may be 



558 DISEASES OF THE SKIN. 

substituted for it, or, even preferably, corrosive sublimate in 
solution, tbree to tour grains to the ounce. Petroleum and olive 
oil witli the balsam of Peru, in the proportions giveu above in 
connection with the subject of pediculosis capitis, is an effective 
combination. Staphysagria, carbolic acid, cocculus indieus, or 
one of the other substances used in the disorders occasioned by 
the animal parasites, may 1"' substituted if desired. 

It is usually better to deter bathing till the reined}- selected 
for the destruction of the lice has been applied on several occa- 
sions, after which a warm water and soap ablution will com- 
monly end the trouble. It is needless to clip the pubic hairs. 
Should an eczematous disorder remain, it requires appropriate 
treatment including hot bathing and the blander unguents. 

PeDICULI AND ACARI TRANSFERRED TO Man FROM THE LOWBB 

Animals rarely thrive in such uncongenial soil, but as a matter 

of exception, occasionally survive such transfer. Thus Gold- 
smith, 1 of Vermont, reports the case of a woman affected with 
intense pruritus, who after sweating profusely observed numbers 
of pigeon- or hen-lice emerging from the sweat-pores. Megnin 2 
reports similar cases under the title prurigo dermanyssique, the 
dermanyssus avium or gallina? being theacarus infesting domes- 
ticated fowls. The disorder is said to be at times epidemic in 
the vicinity of aviaries and pigeon-cotes, hut is always of trifling 
severity. 

Cimex lectularius (Acanthia lectularia, Bugs, or Bed-bugs). 

Strictly speaking, the bug is not a parasite of man, but finds 
its congenial habitat in the bed, bedding, or bed covering, walls 
and floors of apartments occupied by persons of both sexes and 
all ages. It infests also furniture, including chairs, sofas, and 
the cushions of seats occupied in public vehicles and hotels. 
From the cracks, crevices, seams, folds, or other protected points 
where it lias found lodgment, it emerges, usually at night, for 
the purpose of securing its nutriment in the blood of its vic- 
tims. It is a pest as ancient as the day in which Dioscorides 
wrote, since he described it. 

The insect has a rusty or reddish color, this differing slightly 
according as it is or is not distended with blood. It is an apte- 
rous member of the order cimicidje; and is provided with a 
blunt-pointed head, broadly attached to the thorax; two long 
slender antennas; and a three-jointed haustellum capable of pro- 
jection and retraction beneath the head. There are three pairs 
of long slender legs by which it is enabled to accomplish rapid 
movements, two thoracic and four abdominal. The abdomen is 

1 Louisv. Mod. News, Dec. 31, 1881. p. 320. 

2 Les parasites ct les maladies parasitaires chez rbnmmc, les animaux donies- 
tiques, etc., Paris, 1880. 



PEDICULOSIS. 559 

broad, flattened, and oval in shape, with nine segments. The 
parasite emits a disgusting odor, which is much more distinct 
when it is crushed. 

The wound, inflicted by the bug is accomplished with or with- 
out the consciousness of its victim, who in the former case is 
made aware of a transitory prick or sting. Soon after, decidedly 
pruritic burning or stinging sensations are experienced ; and the 
wound becomes the seat of an urticaria] wheal. The lesion then, 
examined soon after the infliction of the wound, is seen to be 
small-pea to bean-sized, and in the form of an elevated and cir- 
cumscribed "button" or papulo-tubercle, either whitish in the 
centre or exhibiting there also the hyperemia which distin- 
guishes its peripheral zone. After it has begun to subside and 
lose its acute features, which may not occur for several hours if 
it be irritated by rubbing or scratching, a minute reddish punc- 
ture may be seen marking the original site of the wound. 

The lesions are usually multiple even when but a single assail- 
ant has been present, the insect taking apparent delight in ob- 
taining its nutriment from several distinct points upon one 
surface. In this way at times its course upon the integument 
may be for a short distance traced. In cases where the pests 
are numerous, as in tilthy dwellings, prisons, ships, and bar- 
racks, and when infants have been attacked, the resulting erup- 
tion is often greatly masked by the scratching and resulting 
excoriations of the surface. In this way vesicles, pustules, crusts, 
purpuric blotches, and even skin infiltrations may be found, 
instead of the rosy or light reddish typical wheals of recent 
cases in patients with fair clean skins. The diagnosis is a mat- 
ter of importance, and upon it may hang a professional reputa- 
tion. Physicians are otten consulted respecting these lesions by 
patients who believe themselves to be suffering from "humors," 
exanthemata, and even syphilis. The insect attacks the parts 
of the body to wdiich access is easy as the patient sits or reclines 
on the back or side, including the buttocks, thighs, shoulders, 
loins, and neck, in that order of frequency, rather more rarely 
the legs, much less frequently the scalp, face, and genitalia. The 
eruption is not to be confounded with urticaria ab ingestis, which 
is more apt to be symmetrical in disposition. 

It is best relieved by the topical application of spirits of cam- 
phor, alcohol, weak carbolated lotions, or solutions of boracic 
acid, one drachm to the pint. Untreated, it disappears sponta- 
neously when the source of the disorder is removed. The most 
effective treatment is by prophylaxis, with soap and hot water, 
of all accessories of the dwelling-house inbauitable by the in 
sects. Once discovered to be present, infested furniture should 
be scrubbed in all its crevices with a saturated solution of cor- 
rosive sublimate in alcohol ; and bed-clothing immersed in boil- 
ing water. 



560 DISEASES OF THE SKIX. 

Otheb rNSECTS, which may persistentty or only occasionally 
attack the human skin, are the flea (pulex penetrans); the 
mosquito and gnat (cdlex pipiens); midges (tipulid^e, semulia) ; 

IPES MELLIFER-fi); and wasps (vk.-IM n.r. i. 

These produce, by their Idles or stings, various cutaneous 
lesions, including urticarial wheals, papules, ecchymoses, and in 
rare eases even ecchymomata. Those produced by the flea are 
found more often on the legs, neck, or orher covered portions of 
the 1) xly ; those of the midge and mosquito on the face, hands, 
and exposed parts; though when numerous and voracious, these 
insects will penetrate the clothing for the purpose of obtaining 
blood. Severe eruptive lesions are often seen in this country on 
the faces and extremities of infants and children exposed during 
the night to the incursions of these marauders. They are usually 
treated locally by aqua amnionic or the spirits of camphor. 



BIBLIOGEAPHY. 



Anderson (McCall). Oh Psoriasis and Lepra. London, 1865. 

On the Parasitic Affections of the Skin. London, 1868. 

On the Treatment of Diseases of the Skin, with an analysis of eleven 

thousand consecutive cases. London, lf->72. 

■ On the Treatment of Diseases of the Skin, with an analysis of eleven 

thousand consecutive cases. Phila. 1873. 

A Practical Treatise upon Eczema, including- its lichenous and impeti- 
ginous forms. Phila. 1875. 

Bazin. Affections cutanees de nature arthritique et dartreuse. Paris, 1868. 

Behrend (Gustav). Die Hautkrankheiten for Aerzte und Studirende darges - 
tellt. Braunschweig, 1879. 

Bulkley. Eczema and its Management. New York, 1881. 

Bumstead and Taylor. The Pathologv and Treatment of Yenereal Diseases, 
4th ed. Phila. 1879. 

Damon (Howard F.). The Structural Lesions of the Skin, their Pathology and 
Treatment. Phila. 1869. 

Despres (Armand). Traite theorique et pratique de la Syphilis, ou infection 
purulente syphilitique. Paris, 1873. 

Dowse (Thomas S.). On some Diseases of the Skin which are produced by de- 
rangements of the Nervous System. London, 1880. 

Duhring. A Practical Treatise of Diseases of the Skin, 3d ed.- Phila. 1882. 

Fournier. Lecons sur la Syphilis etudiee plus particulierement chez la feinine. 
Paris, 1873. 

Fox (Tilbury). Skin Diseases; their description, pathology, diagnosis, and 
treatment. Second American, from the third English edition. New York. 1873. 

Fox (Tilbury) and Fox (T. C). Epitome of Skin Diseases, with Formula? for 
Students and Practitioners. Phila. 1876. 

Gaskoin (George). On the Psoriasis or Lepra. London, 1875. 

Hardy. Lecons sur les Maladies dartreuses. Troisieme edition. Paris, 1868. 

Hebra. Handbuch der Speciellen Pathologie und Therapie. Erlaiigen, 1860. 

Hebra and Kohn. Handbuch der Speciellen Pathologie und Therapie. Er- 

langen, 1870. 

Hebra and Kaposi. Handbuch der Speciellen Pathologie und Therapie. Er- 
langen, 1872. 

Handbuch der Speciellen Pathologie und Therapie. Erlangen, 1874. 

On Diseases of the Skin, including the Exanthemata. New Sydenham 

Society's translation, vols. i.-v. London, 1866-1878. 

Heitzmann. Microscopical Morphology of the Animal Body. N. York, 1883. 
Jullien (L.). Traite pratique des Maladies Veneriennes. Paris, 1879. 

86 (561) 



562 BIBLIOGRAPHY. 

Kaposi. Syphilis der limit and der angrenzenden Schleimhaute. Wien, 1873, 
L874, L875. 

Pathologie and Therapie der Bautkrankbeiten. Zweite verb. a. verm. 

Anil. Wien and Leipzig, 1882. 

Keyes (K. L.). The Venereal Diseases, etc. New York, 1880. 

Kuchenmeistkr. On Animal and Vegetable Parasites of the Human Body. 
London. L857. 

Lancerbaux (E.). Traite historiqae et pratique de la Syphilis. Paris. 1874. 

Leonard (C. Henri). The Hair; its growth, care, diseases, and treatment. 

Detroit. 1- 

Liveinq (Robert). Notes on the Treatment of Skin Diseases. Now York. 

A Handbook on the Diagnosis of Skin Diseases. New York, L879. 

Meonin, P. Les parasites et lea maladies parasitaires. Paris, 1880. 

Milton (J. L.). The Pathology and Treatment of Diseases of the Skin. London. 
1872. 

Morris (Malcolm). Skin Diseases, including their definition, symptoms, diag- 
nosis, prognosis, morbid anatomy, and treatment. A Manual for Students and 
Practitioners. Phila. L880. 

Neumann (L). Handbook of Skin Diseases. Translated from the second German 
edition, with Notes, by Lucius D. Bulkley. New York. 1872. 

Lebrbuch der Hautkrankheiten. Dritte Anflage. Wien, 1873. 

Piffard (H. GL). A Treatise on the Materia Medica and Therapeutics of the 
Skin. New York, 1881. 

Piffard ( H. G.) and Fox (G. H.). Cutaneous and Venereal Memoranda. New 

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Smith (Alder). Ringworm; its Diagnosis and Treatment. Phila. 1881. 
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The Pharmacopoeia of the British Hospital for Diseases of the Skin. 

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Sturois (F. R.). The Student's Manual of Venereal Diseases. New York. 1 880. 

Van Buren and Keyes. A Practical Treatise on the Surgical Disease.- of the 
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INDEX. 



ACANTHIA lectularia, 558 
Acarus folliculorum, 544 
scabiei. 539 
Achorion Schoenleinii, 505 
Achromia, 382 
acquired, 383 
congenita], 382 
Acne, 305 

artificialis, 306 
atrophica, 306 
cachecticorum, 306 
diagnosis of, 309 
etiology of, 308 
hypertrophica, 306 
indurata, 306 
papulosa, 307 
pathology of, 309 
punctata, 307 
pustulosa, 307 
rosacea, 314 

diagnosis of, 316 
etiology of, 315 
pathology of, 316 
prognosis of, 318 
treatment of, 317 
symptomatology of, 305 
treatment of, 310 
varioliformis, 308 
vulgaris, 308 
Aconite, eruptions produced by, 168 
Addison's keloid, 256 

disease, skin color in, 378 
Adenoma, 281 
Adenome sudoripare, 492 
Adipose tissue, 42 
Ainhum, 421 
Albinism, 382 
Albinoes, 382 
Aleppo evil, 197 
Alopecia, 330 
areata, 333 

diagnosis of, 335 
etiology of, 334 
pathology of, 334 
prognosis of, 336 
symptomatology of, 333 
treatment of, 335 
congenital, 330 
furfuracea, 337 
premature, 331 
senilis, 330 
treatment of, 332 
AnEesthesia, 370 
Anaesthetic leprosy, 371 



Anatomy and physiology of the skin, 17 

of the skin, 17 
Anderson's dusting powder, 88 
Angioma, 358 

cavernosum, 360 

etiology of, 360 

pathology of, 360 

treatment of, 361 
Anidrosis, 321 

treatment of, 322 
Anthrax, 193 

diagnosis of, 195 

pathology of, 194 

prognosis of, 196 

symptomatology of, 193 

treatment of, 195 
Appendages of the skin, 18 
Area Celsi, 353 
Argyria, 378 

Arnica, dermatitis from, 166 
Arreetores pilorum, 28 
Arsenic, eruptions produced by, 168 

value of, 70 
Arteries of the skin, 24 
Asiatic pill, 71 
Asteatosis, 304 

prognosis of, 304 

symptomatology of, 304 

treatment of, 304 
Atrophia cutis, 259 

pilorum propria, 337 

senilis, 261 
Atrophy of nail, 352 
Atropia, eruption produced by, 169 

BALDNESS, 330 
Bandages, 76 
Barbers' itch, 525 
Baths, alkaline, acid, etc., 100 
Bedbug, 558 

Belladonna, eruption produced by, 169 
Biskra bouton, 197 
Black-heads, 295 
Black measles, 399 
Blanching atrophy of the skin, 260 
Blebs, 4,9 

Bleeding stigmata, 373 
Bloodvessels of the skin, 24 
Bloody sweat, 323 
Boils, 190 

Boracic acid, eruption produced by, 169 
Bromides, eruption produced by, 169 
Bromidrosis, 320 

treatment of, 321 

(563) 



►64 



INDEX. 



Bromine and its compounds, eruptions 

produced by, 169 
Bogs, 558 
Ball*. 49 

hnmorrhagicsB, 854 
Burmese ringworm, 517 
Burns, 1 62 

CACOTROPHIA folliculorum. 347 
Cadaveric infection, pustules of, 196 
Callositai 
Callosities. 235 

Calotte, r ; iis 

Cancer, connective tissue, 496 

, n cuirasse, 497 

fibrous, 497 

hard, 497 

lenticular, 407 

scirrhous, 497 

skin, 488 

tuberose, 497 
Canities, 340 

symptomatology of, 340 

treatment of, .;41 
Cannabis Indica, eruption produced by, 

170 
Carbolic acid, 72 
Carbuncle, 193 
Carcinoma, 488 

etiology of, 490 

melanotic, 497 

pathology of, 491 

pigmented, 497 

prognosis of, 496 

treatment of, 494 

tuberose, 497 
Chagres fever, color of skin in, 378 
Chancre, 436 

Hunterian, 437 
Chancroid, 483 
Cheiro-pompholyx, 329 
Chicken-pox, 398 
Chilblain, 164 
Chloasma, 377 

cnchecticorum, 378 

diagnosis of, :i7'.> 

pathology of, 379 

symptomatology of, 377 

treatment of, 379 

uterinum, 377 
Chloral-camphor, 368 

eruption produced by, 170 
Chromidrosis, 822 
Chrysarobin, 211 
Cicatrices, 53 

Cimex lectularius, 558 • 

Claret-stain, 859 
Classification of skin diseases, 77 

of Amer. Derm. Ass., 80 
of author, 78 
of Hebra, 78 
Clavus, 236 
Cod-liver oil, eruption produced by, 170 

value of, 71 



Colored sweat, 322 
Columnre adiposi 
Comedo, 294 

diagnosis of, 297 

etiology of, 295 

pathology of. 296 

prognosis of, 300 

symptomatology of, 294 

treatment of, 298 
Condyloma, 449 
Congenital alopecia, 330 
Connective tissue, subcutaneous, 42 
Copaiba, eruption produced by, 170 
Corinm, '22 
Corn, 236 

Cornu cutaneum, 237 
Corpuscle, Meissner, 27 

Pacinian, 26 

tactile, 27 

Wagner, 27 
Cosme's paste, 494 
Crab-louse, 556 

Croton oil, dermatitis from, 165 
Crusta lactea, 140 
Crusts, 52 

Ctibebs, eruption produced by, 1 70 
Cundurango, eruption produced by, 171 
Curette, 77 
Cutaneous hemorrhages, 353 

pathology of, 357 

treatment of, 358 
Cuticle, 18 
Cutis testacea, 287 
Cylindroma, 492 
Cysticercus cellulosse, 547 

DANDRUFF, 284 
Delhi boil, 197 
Demodex folliculorum, 544 
Depilatories, 350 
Dermanyssus avium, 558 
Dermatalgia, 371 
Dermatitis, 162 

calorica, 162 

exfoliativa generalis, 218 

from aniline, 166 

gangrenosa, 165 

medicamentosa, 168 

papillaris capillitii, 345 

traumatica, 164 

venenata, 165 
Dermatolysis, 250 

diagnosis of, 251 

etiology of, 251 

pathology of, 251 

prognosis of, 251 

symptomatology of, 250 

treatment of, 251 
Diachylon ointment of Hebra, 132 
Diagnosis, general, 61 
Digitalis, eruption produced by, 171 
Dipterous larvae in the skin, 548 
Discoloration, 376 
Dissection wounds, 196 



565 



Dusting powders, 75 

Anderson's, 88 

Klamanri's, 88 
Dyes for the hair, 341 
Dysidrosis, 329 

ECCHYMOMATA, 354 
Ecchymoses, 354 
Ecthyma, 188 

diagnosis of, 189 

etiology of, 188 

pathology of, 189 

prognosis of, 190 

symptomatology of, 188 

treatment of, 189 
Eczema, 102 

acute, 110 

and acne, diagnosis between, 117 

and dermatitis, diagnosis between,! 1 7 

and erysipelas, diagnosis between,118 

and erythema, diagnosis between, 118 

and herpes, diagnosis between, 118 

and impetigo, diagnosis between, 118 

and impetigo contagiosa, diagnosis 
between, 118 

and lichen ruber, diagnosis between, 
119 

and lupus, diagnosis between, 119 

and pediculosis, diagnosis between, 
119 

and pemphigus, diagnosis between, 
120 

and pityriasis rubra, diagnosis be- 
tween, 120 

and prurigo, diagnosis between, 120 

and pruritus, diagnosis between, 120 

and psoriasis, diagnosis between, 120 

and scabies, diagnosis between, 121 

and scarlatina, diagnosis between, 121 

and seborrhoe*.,diagnosis between, 122 

and sycosis, diagnosis between, 122 

and syphilis, diagnosis between, 122 

and tinea circinata, diagnosis be- 
tween, 123 

and tinea favosa, diagnosis between, 
123 

and tinea versicolor, diagnosis be- 
tween, 123 

as it affects the nails, 161 

chronic, 111 

constitutional treatment of, 138 

diagnosis of, 117 

erythematous, 103 

etiology of, 111 

fissum, 109 

intertrigo, 109 

local varieties of, 140 

madidans, 109 

marginatum, 88, 512 

of the anus and anal region, 154 

of the beRrd, 149 

of the ears, 147 

of the face, 143 

of the genital organs, 151 



Eczema — 

of the hands and feet, 159 

of the lids, 148 

of the lips, 145 

of the nipple and breast of the fe- 
male, 155 

of the nipple and cancer of the breast, 
156 

of the nose, 146 

of the scalp, 140 

of the superior and inferior extremi- 
ties, 157 

of the umbilicus, 156 

pnpulai', 107 

pathology of, 114 

prognosis of, 139 

pustular, 106 

rubrum, 109 

sclerosum, 110 

squamous, 109 

symptomatology of, 102 

treatment of, 123 

verrucosum, 109 

vesicular, 104 
Elephantiasis, 246 

diagnosis of, 248 

etiology of, 248 

Grsecorum, 423 

pathology of, 248 

prognosis of, 249 

symptomatology of, 246 

telangiectodes, 250 

treatment of, 249 
Epidermis, 18 
Epilating sticks, 508 
Epilation, 341, 508 
Epithelial cancer, 488 
Epithelioma, 488 

diagnosis of. 493 

papillary, 490 
' superficial, 488 

tubercular, 489 
Equinia, 228 
Erectores pilorum, 28 
Ergot, value of, 72 
Erysipelas, 410 

ambulans, 41 1 

diagnosis of, 413 

etiology of, 413 

pathology of, 413 

prognosis of, 415 

recurrent and chronic forms of 412 

symptomatology of, 410 

treatment of, 414 
Erythema annulare, 91 

bullosum, 91 

caloricum, 85 

diaguosis of, 85 

figuratum, 91 

idiopathic, 84 

intertrigo, diagnosis of, 87 
etiology of, 87 
symptoms of, 86 
treatment of, 88 



566 



INDBX. 



Erythema — 

iris, '.'1 

marginatum, 01 
multiforme, diagnosis of, 98 

etiology of, 

pathology of, 92 

symptoms ol 
treatment i 

nodosum, ''1 

papalatom, 1 

papulosum, 01 

simplex, symptoms of, 84 

symptomatic, B5 

tranmaticum, - 1 

treatment of, B6 

articatnm, 91 

venenatum, 85 

vesiculosum. 91 
Etiology, general, 56 
Exanthemata, '■>'> 
Excoriations, 

neurotic, Z'i 3 
Exudative diseases of the skii 

TjURCY. 

JT Fat columns of the thick derma, 43 

Favus, 508 

diagnosis of. 507 

etiology of, 505 

pathology of, 506 

treatment of, 
Fibroma. 276 

fungoides, 502 
Fibro-myoma, 282 
Filaria medinensis, 545 

sanguinis, 545 
Fish-skin disease, 242 
Fissures, 51 
Fleas, 560 

Follicles, hair, anatomy of, 30 
Foot, perforating nicer of, 422 
Framboesia, 434 
Framboesioid condylomatous syphiloderm, 

449 
Freckles. 376 
French measles 

Friction, etiological effects of, 58 
Fungous foot of India, 121 
Furunculosis, 190 

diagnosis of, 192 

etiology of, 191 

pathology of, 191 
prognosis of, 193 
symptomatology of, 100 
treatment of, 102 

GALACTIDROSIS, 324 
Gangrene, superficial, 373 
General diagnosis, 61 
etiology, 56 

exfoliative dermatitis, 218 
symptomatology, 45 

therapeutic 



German measles, 380 

Giant wheal-. 

Glanders, 

Glands, sebaceous, anatomy 

sweat, anatomy of, 37 
Glossy fingers, 2'11 
Glycerine, To 

Glycerole of the subacetate of lead, 136 
Goa powder iu psoriasis, 21 1 
i Green soap, 76 
Guinea worm, 545 
Gumma, 158 
Gummy tumor, 458 

H.KM ATI MIOSIS, 323 
Haemorrhage, cutaneous, 353 
Hemorrhagic bullae, 354 
purpura. : '•"> 1 
variola, 
Hair-dyes, 341 
Hair, hypertrophy of, 348 

follicles of. 30 
new growth of, 35 
Head-lou- 

Heat, etiological effect of, 57 
Hebra's method of treatment in chronic 

eczema, 135 
Hemiatrophia facialis. 254 
Hereditary syphilis, 45'.' 
Heredity in cutaneous diseases 
Herpes, 170 

facialis, 177 
iris, 170 
labialis, 177 
progenitalis. 177 
symptomatology of, 170 
treatment of, 178 
zoster. 180 

diagnosis of, 183 
etiology of, 182 
path dogy of, 182 
prognosis of, 184 

symptomatology of, 180 

treatment of, 184 
Hide- bound skin, 253 
Hirsuties, 
Hives, 94 

Horns, cutaneous, 237 
Horny layer of epidermis, 18 
Hyperaeniic diseases of the skin. 83 
Hyperesthesia, 370 
Hyperidrosis, 318 
Hypertrophy of hair, 348 

etiology of, 349 

treatment of, 3 19 
of nail, 351 

symptomatology of, 351 

treatment of, 352 

ICHTHYOSIS, 212 
1 diagnosis of, 245 

etiology of, 2 1 1 

hystrix, 243 



567 



Ichthyosis — 

pathology of, 244 
prognosis of, 246 
sebacea, 287 
simplex, 243 
symptomatology of, 242 
treatment of, 245 
Impetigo, 184 

contagiosa, 186 

diagnosis of, 187 
etiology of, 186 
pathology of, 186 
treatment of, 188 
diagnosis of, 185 
etiology of, 185 
herpetiformis, 223 

symptomatology of, 223 
pathology of, 185 
symptomatology of, 184 
treatment of, 186 
Inflammatory fungoid neoplasm, 502 
Insects other than lice attacking the hu- 
man skin, 560 
Instruments available in treating the skin, 

77 
Intertrigo, 86 

Iodine and its compounds, eruption pro- 
duced by, 171 
value of. 7i 
Iodized phenol, 136 
Itch, 536 
Ixodes, 549 

KELOID, 273 
diagnosis of, 275 

etiology of, 274 

of Addison, 256 

pathology of, 274 

prognosis of, 275 

symptomatology of, 273 

treatment of, 275 
Keratosis, 235 

due to epidermal hypertrophy, 235 

due to hypertrophy of the derma, 238 

pilaris, 346 

symptomatology of, 346 
Kerion Celsi, 524 
Klamann's dusting powder, 88 

LA ROSA, 432 
Lamp for fumigation in syphilis, 477 
Land scurvy, 354 
Lentigo, 376 

etiology of, 376 

symptomatology of, 376 
Leontiasis, 525 
Lepra, 423 

ansestbetica, 427 

Arabum, 423 

diagnosis of, 431 

etiology of, 328 

maculosa, 426 

mutilans, 426 

pathology of, 430 



Lepra — 

prognosis of, 432 
symptomatology of, 423 
treatment of, 431 
tuberosa, 424 
Leprosy, 423 

Lombardy, 432 
Leptus, 547 
Lesions, 46 
Leucoderma, 382 
Lice of the body, 552 
of the head, 550 
of the pubes, 556 
Lichen ruber, 225 

acuminsitus, 224 
diagnosis of, 225 
etiology of, 225 
pathology of, 225 
planus, 224 
prognosis of, 226 
symptomatology of, 224 
treatment of, 226 
scrofulosorum, 418 
tropicus, 325 
urticatus, 95 
Light, etiological effect of, 57 
Liquor picis alkalinus, 134 
Lombardy leprosy, 432 
Lousiness, 549 
Lupus disseminatus, 268 
erythematosus, 263 
diagnosis of, 265 
etiology of, 264 
pathology of, 364 
prognosis of, 267 
symptomatology of, 263 
treatment of, 266 
exedens, 268 
exfoliativus, 268 
hypertropbicus, 268 
serpiginosus, 268 
tuberculosus, 268 
vegetans, 268 
verrucosus, 268 
vorax, 268 
vulgaris, 267 

diagnosis of, 270 
etiology of, 268 
pathology of, 269 
symptomatology of, 267 
treatment of, 271 
Lymphadenie cutande, 502 
Lymphangiectasic fibro-myoma. 282 
Lymphangioma cutis, 363 
Lymphatics of the skin, 25 
Lymph-scrotum, 546 
Lyomyomata, 281 

MACULAE, 46 
Macular syphiloderm, 442 
Malabar itch, 517 
Maliasmus, 228 
Malignant pustule, 229 
Measles, 386 






INDEX. 



Measlc 

black, 390 
German, 389 
Medicinal rashes, diagnosis of, 175 
Medullated nerve fibres of the skin, 2G 
Melanoderma, 377 

cachecticoru 
Mercury, eruption produced by, 172 

value of, 71 
Microscope, value of, in diagnosis, 66 
Microsporon furfur. 
Miliaria, 

alba, 325 
crystallina, 325 
diagnosis of, 327 
etiology of. 326 
papulosa, • 
pathology of, 320 
prognosis of, 328 
rubra, 32-3 

symptomatology of, 325 
treatment of, 328 
vesiculosa, 325 
Miliary fever, 328 
Milium. 300 

diagnosis of, 302 
etiology of, 301 
pathology of, 301 
symptomatology of, 300 
treatment of, 302 
Milk crust, 140 
Moles, pigmentary, 381 
Molluscous corpuscles, 232 
Molluscum contagiosum, 230 
epitbeliale, 230 

diagnosis of, 233 
etiology of, 231 
pathology of, 232 
prognosis of, 235 
symptomatology of, 230 
treatment of, 235 
fibrosum, 276 

diagnosis of, 278 
etiology of, 277 
pathology of, 277 
prognosis of, 278 
symptomatology of, 276 
treatment of, 278 
Morbilli, 386 

Morbus maculosus Werlhoffii, 354 
Morphoea, 256 

diagnosis of, 258 
etiology of, 257 
pathology of, 258 
symptomatology of, 256 
treatment of, 258 
Mucous patches, 449 
Multiple cutaneous tumor accompanied 

by pruritus, 241 
Muscles of the skin, 26 
non-striated, 26 
striated, 20 
Mycetoma, 421 
Mycosis fongoide, 502 



Mycosis frambixsioides, 134 
Myelom i 

diagnosis of, 501 

etiology of, 

pathology of, 500 

prognosis of, 501 

symptomatology of, 408 

treatment of, 501 
Myoma cutis, 281 

telangiectodes J s 2 
Myringomycosis, 535 

\TJEVI pigmentosi, 348 
1\ pilosi, 34fi 
Naevus lipomatodes, 381 

mollusciformis, 381 

pigmentosus, 381 

pilosus, 381 

spilus, 381 

vasculosus, 359 

verrucosus, 381 
Nails, anatomy of, 40 

atrophy of, 352 

hypertrophy of, 351 
Names of cutaneous symptoms, list of, 54 
Nerves of the skin, 26 
Nettle-rash, 94 
Neuroma, 373 

symptomatology of, 373 
Neurotic excoriations, 373 
Nits, 551 

Nodose swellings of shafts of hairs, 338 
Non-medullated nerve fibres of the skin, 26 
Non-parasitic sycosis, 341 
Norwegian scabies, 537 

ODOROUS emanations from the skin, 39 
QEstrus bovis, 548 
Ointments, 75 
Onychia, 351 

syphilitic, 352 
Onychogryphosis, 351 
Onychomycosis, 351, 512 
Opium and its alkaloids, eruption pro- 
duced by, 172 

PACINIAN corpuscles, auatomy of, 26 
Paget's disease, 156 
Palmar and plantar syphilodermata, 450 
Panniculus adiposus, 42 
Papilloma, 242 
Papulaj, 47 

Parangi disease of Ceylou, 435 
Parchment skin of llebra, 250 
Paronychia, 351 
Pars papillaris, 23 

reticularis, 24 
Pediculi and acari transferred to man 

from the lower animals, 558 
Pediculosis, 519 

capitis, 550 

corporis, 552 

pubis, 556 

symptomatology of, 549 



569 



Pediculosis — 

vestimenti, 552 
Peliosis rheumatica, 355 
Pellagra,- 432 
Pemphigus foliaceus, 221 

vulgaris, 214 

diagnosis of, 216 
etiology of, 215 
pathology of, 215 
prognosis of, 218 
symptomatology of, 214 
treatment of, 217 
Perforating ulcer of the foot, 422 
Pernio, 164 
Petechia, 354 
Phosphorus, 72 

eruption produced by, 173 
Phtheiriasis, 549 

Physiological changes, effects of, 60 
Physiology of the skin, 17 
Pian, 434 
Piebald skin, 382 
Piedra, 340 
Pigeon-lice. 558 
Pigment, 27 
Pigmentary moles, 381 

syphiloderm, 444 
Pityriasis capitis, 337 

maculata et circinata, 214 

rubra, 219 

diagnosis of, 220 
etiology of, 220 
pathology of, 220 
treatment of, 221 

tabescentium, 287 
Plantar syphiloderm, 450 
Plaque muqueuse, 449 
Plasters, 75 
Plica polonica, 348 
Podelcoma, 421 

Podophyllin, eruption produced by, 173 
Poison-ivy, 165 
Poisoned wounds, 196 
Pomades, 75 
Port-wine marks, 359 
Powders, dusting, 75 
Precautions to be observed in the general 

management of tinea favosa, etc., 530 
Premature alopecia, 331 
Prickle-cells, 21 
Prickly heat, 325 

Prognosis of cutaneous diseases, 67 
Prurigo, 226 

agria, 227 

dermanyssique, 558 

diagnosis of. 228 

etiology of, 227 

ferox, 227 

mitis, 227 

pathology of, 228 

prognosis of, 228 

symptomatology of, 226 

treatment of, 228 
Pruritus, 364 



Pruritus — 

diagnosis of, 366 

etiology of, 365 

hiemalis, 369 

pathology of, 366 

senilis, 365 

symptomatology of, 364 

treatment of, 366 
Psoriasis, 198 

and eczema, diagnosis between, 202 

and favus, diagnosis between, 203 

and lichen ruber, diagnosis between, 
203 

and lupus erythematosus, diagnosis 
between, 203 

and seborrhcea, diagnosis between, 
204 

and syphilis, diagnosis between, 204 

and tinea circinata, diagnosis be- 
tween, 205 

circinata, 199 

diagnosis of, 202 

diffuse, 199 

etiology of, 200 

figurata, 199 

guttata, 198 

gyrata, 199 

nummularis, 199 

orbiculosus, 199 

pathology of, 201 

prognosis of, 213 

punctata, 198 

symptomatology of, 198 

treatment of, 205 
Pulex penetrans, 545 
Purpura hemorrhagica, 354 

pulicosa, 354 

rheumatica, 355 

scarlatina, 356 

simplex, 356 

urticans, 356 

urticata, 95 
Pustula maligna, 229 
Pustules, 50 

and other lesions resulting from 
wounds inflicted by reptiles and 
insects, 197 

from cadaveric infection, 196 



Q 



UININE and its alkaloids, eruptions 
produced by, 173 
value of, 72 



REPTILES and insects, lesions produced 
by, 197 
Rete Malpighii, 20 

mucosum, 20 
Rhagades, 51 
Rheumatic purpura, 355 
Rhinocoprion penetrans, 545 
Rhinophyma, 315 
Rhinoscleroma, 282 

diagnosis of, 283 

etiology of, 283 



570 



. X D E X . 



Rhinoscleroma — 

pathology i :. 

progn 

symptomatology of, 282 

treatment :. 
Rhus toxicodendron, eruption produced 

by, 165 
Ringworm of the beard, 525 

of the body, 510 

of the nail, 512 

of the scalp, 518 
Risipoln Lombnrda, 482 
Rodent ulcer, 488 
Rosacea, '■'■*'•<) 
Roseola. 85 

syphilitica, 442 
Rotheln, 
Rubella, 389 
Rubeola. 88b" 
Rupio, 455 

SALICYLIC ACID and the salicylates, 
eruptions produced by, 174 
Santonine. eruption produced by, 174 
Sapo viridis, 70 
Sarcoma, 498 
Sarcoptes, 588 
Scabies, 536 

diagnosis of, 541 

etiology of, 538 

pathology of, 539 

prognosis of. 544 

symptomatology of, 536 

treatment of, 542 
Scales, 51 
Scarf-skin, 18 
Scarlatina, 390 
Scarlatiniform typhus, 393 
Scarlet fever, 390 
Scars, 53 

Scirrhous cancer, 497 
Sclerema neonatorum. '2 •"> 1 
diagnosis of, 252 
etiology of, 252 
pathology of, 252 
symptomatology of, 251 
treatment of, 252 
Scleroderma, 253 

diagnosis of, 255 

etiology of, 254 

pathology of, 254 

prognosis of, 256 

symptomatology of, 253 

treatment of, 255 
Scorbutic purpura, 356 
Scrofuloderm, large pustular, 419 

papular, 418 

small pustular, 418 

ulcerative, 502 
Scrofuloderma, 416 

diagnosis of, 419 

etiology of, 419 

prognosis of, 420 

symptomatology of, 416 



Scrofuloderma — 

treatment of, 419 
Scurvy, 356 

Season?, etiological effect of, 58 
Sebaceous cysts, 300 

glands, anatomy of, 35 
Seborrhcea, 284 

and eczema, diagnosis between, 289 

and ichthyosis, diagnosis between, 200 

and impetigo, diagnosis between, 290 

and impetigo contagiosa, diagnosis 
between. 290 

and keratosis pilaris, diagnosis be- 
tween, 290 

and lupus erythematosus, diagnosis 
between, 290 

and psoriasis, diagnosis between, 291 

and syphilis, diagnosis between, 2 '1 

and tinea circinata, diagnosis be- 
tween, 291 

and tinea tonsurans, diagnosis be- 
tween, 291 

capillitii, 285 

diagnosis of, 289 

etiology of, 288 

faciei, 286 

generalis, 2S7 

genitalium, 287 

oleosa, 288 

pathology, of, 289 

prognosis of, 294 

sicca, 285 

squamosa, 285 

symptomatology of, 284 

treatment of, 291 

trunci, 287 
Sebum, 37 
Senile alopecia, 330 
Septum lucidum, 20 
" Skin worms," 295 
Smallpox, 395 

confluent, 400 

invasion rashes of, 395 
Soaps, 76 

hard, 76 

soft, 76 
Sodium benzoate, eruptiou pruduced by, 
174 

biborate, eruption produced b}', 174 
Spirit of green soap. 76 
Spiritus s.iponis kalinus, 76 
Squamae, 51 

Steatozoon folliculorum, 544 
Stramonium, eruption produced by, 174 
Stratum corneum, 18 

mucosum, 20 
Striae et macula 1 atrophica?, 261 
Strychnia, eruption produced by, 174 
Subcutaneous tissues, anatomy of, 42 
Subjective symptoms, 45 
Sudamina, 324 

Sudoriparous glands, anatomy of, 37 
Superficial gangrene of the skin, 373 



571 



Surgical appliances in diseases of the 

skin, 76 
Sweat glands, anatomy of, 37 
Sycosis non-parasitica, 341 
diagnosis of, 343 
etiology of, 342 
pathology of, 343 
prognosis of, 345 
symptomatology of, 341 
treatment of, 343 
Symptomatology, general, 45 
Synovial lesions of the skin, 423 
Syphilis, "tonic" treatment of, 473 
Syphilitic onychia, 352 

roseola, 442 

vegetations, 449 
Syphiloderm, erythematous, 442 

frambcesioid condylomatous, 449 

large acuminate papular, 446 

large acuminate pustular, 453 

large flat papular, 448 

large flat pustular, 454 

palmar and plantar, 450 

pigmentary, 444 

serpiginous tubercular, 456 

small acuminate papular, 445 

small acuminate pustular, 453 

small flat papular, 447 

small flat pustular, 454 
Syphiloderma, 435 

bullosum, 455 

diagnosis of, 466 

etiology of, 464 
•general characteristics of, 438 

gummatosum, 458 

hsereditarium, 459 

infantile, 459 

maculosum, 442 

papillosum, 445 

pathology of, 465 

prognosis of, 482 

pustulosum, 452 

treatment of, 468 

tuberculosum, 455 

vesiculosum, 452 

TACTILE corpuscles, 27 
Tanacetum, eruption produced by, 
174 
Tar, eruption produced by, 175 

vilue of, 72 
Tattooing, 379 
Telangiectasis, 359 

Terms descriptive of cutaneous symp- 
toms, list of, 54 
The itch, 536 
Therapeutics, general, 68 
Tick, 549 

Tinea circinata, 510 
cruris, 88 
diagnosis of, 514 
etiology of, 512 
pathology of, 513 
prognosis of, 517 



Tinea circinata — 

symptomatology of, 510 

treatment of, 515 
favosa, 503 

symptomatology of, 503 
imbricata, 517 
kerion, 523 
sycosis, 525 

diagnosis of, 528 

etiology of, 526 

pathology of, 527 

prognosis of, 530 

symptomatology of, 525 

treatment of, 529 
tonsurans, 518 

diagnosis of, 521 

etiology of, 519 

pathology of, 520 

prognosis of, 523 

symptomatology of, 518 

treatment of, 522 
trichophytina, 510 

cruris, 512 

unguium, 512 
versicolor, 531 

diagnosis of, 533 

etiology of, 532 

pathology of, 532 

prognosis of, 525 

symptomatology of, 531 

treatment of, 534 
Tokelau ringworm, 517 
Toxicants, effects of, 59 
Traumatism, effects of, 58 
Trichophyton, 513 
Trichorexis nodosa, 338 
Tubercles, 48 

Tuberculosis of the skin, 420 
Tuberose carcinoma, 497 
Tumors, 48 

Turpentine, eruption produced by, 175 
Tyloma, 235 

IJLCERS of the skin, 53 
J Undescribed form of atrophy of hail 
and beard, 338 
Uridrosis, 324 
Urticaria ab ingestis, 96 
annularis, 95 
bullosa, 95 
diagnosis of, 98 
etiology of, 96 
evaniua, 95 
figurata, 95 
hsemorrhagica, 95 
papulosa, 95 
pathology of, 97 
perstans, 95 
pigmentosa, 95 
prognosis of, 101 
symptoms of, 94 
treatment of, 99 
tuberosa, 95 
vesiculosa, 95 



57! 



INDEX. 



VACCINATION, 106 
syphilis transmitted by, 408 
Vaccinia, #06 

Varied i 
Variola 

confluent, 400 

diagnosis of, 404 

etiology of, 401 

pathology of, 402 
1U"- 

treatment of, 404 
Varioloid, 399 

as erythema, 395 

roseola, 895 
Vaeeliue, 75 
Veins of the skin, 24 

tores, 262 
Verruca, 238 

acquisita, 239 

acuminata, 288 

congenita, 239 

etiology of, 239 

filiformis, 2 

glabra, 239 

pathology of, 240 

plana, 239 

prognosis of, 241 

senilis, 239 

treatment of, 241 

vulgaris, 239 
Vesicles, 49 
Vitiligo, 383 

diagnosis of, 384 

etiology of, 384 

pathology of, 384 

prognosis of, 385 



Vitiligo — 

symptomatology of, 383 
treatment of, 

Vleminckx's solution, 313 

WARTS, 238 
Water, therapeutic employment of, 73 
Wens. 302 

diagnosis of, 303 
pathology of, 303 
symptomatology of, 302 
treatment of, 303 
Wheals, 47 
Wilkinsou's ointment as modified by Ile- 

bra, 210 
Wood-tick, 549 

XANTHOMA, 279 
diagnosis of, 280 
etiology of, 28U 
multiplex, 279 
pathology of, 280 
planum, 279 
prognosis of, 281 
symptomatology of. 279 
treatment of, 281 
tuberculosum, 279 
Xeroderma, 2-J9 

VAWS, 434 



ZONA, 180 
Zoonoses, 228 

Zoster, 180 



E R R A T A . 



" 76, 

" 89, 

" 102, 

" 110, 

'■ 120, 

" 162, 

" 211, 

" 238, 

•• 272, 

" 313, 

" 319. 



line 8, for l>< . read may be. 

3d paragraph, line 11, and page 113. 2d paragraph, line 12, for castor, 

read <-rnt, w . 
2d paragraph, line 12. for charron, read Carron. 
derivation of eczema, (orjlow, road boil. 
4th paragraph, lino 9, for may, by, road may udrancr- by. 
last lino, for cures, read cases. 
3d paragraph, lino 14, for excited, read exerted. 
the last sentence of tin- first paragraph should apply to formula in 

foot-note of page 313. 
last paragraph, lino 2. for coxcomb, road cock's comb. 
3d paragraph, lino i;. for lower, road larger. 
3d paragraph, lino 14. for Vlemincx's, road Vleminckx's; and the same 

correction in foot-note. 
4th paragraph, lino 7. for symmetrical, road asymmetrical. 



HENRY C. LEA'S SON & CO.'S 

(LATE HENRY C. LEA) 

CLASSIFIED CATALOGUE 

OF 

MEDICAL AND SURGICAL 

PUBLiIOATIOMS. 

In asking the attention of the profession to the works advertised in the following 
pages, the publishers would state that no pains are spared to secure a continuance of 
the confidence earned for the publications of the house by their careful selection and 
accuracy and finish of execution. 

The large number of inquiries received from the profession for a finer class of bind- 
ings than is usually placed on medical books has induced us to put certain of our 
standard publications in half Russia, and that the growing taste may be encouraged, 
the prices have been fixed at so small an advance over the cost of sheep, as to place it 
within the means of all to possess a library that shall have attractions as well for the 
eye as for the mind of the reading practitioner. 

The printed prices are those at which books can generally be supplied by book- 
sellers throughout the United States, who can readily procure for their customers any 
works not kept in stock. Where access to bookstores is not convenient, books will be 
sent by mail post-paid on receipt of the price, and as the limit of mailable weight has 
been removed, no difficulty will be experienced in obtaining through the post-office 
any work in this catalogue. No risks, however, are assumed either on the money or 
on the books, and no publications but our own are supplied, so that gentlemen will in 
most cases find it more convenient to deal with the nearest bookseller. 

A handsomely illustrated catalogue will be sent to any address on receipt of a three 
cent stamp. 

HENKY C. LEA'S SON & CO. 

Nos. 706 and 708 Sansom St., Philadelphia, February, 1S83. 



PROSPECTUS FOR 1833. 

A NEW WEEKLY MEDICAL JOURNAL, 



SUBSCEIPTIOlf BATES. 

The Medical News .FiveDollars. 

The American Journal of the Medical Sciences . FiveDollars. 

COMMUTATION KATES. 
The Medical News ) NineDollars per 

The American Journal of the Medical Sciences } annum, in advance. 

THE MEDICAL NEWS. 

A. National Weekly Medical Periodical, each Number containing 28 to 
32 Double-Columned Quarto Pages exclusive of Advertisements. 

The unprecedented growth of the subscription list of The Medical News during 
L882, is gratifying to all concerned in its publication, not only as assuring its continued 
success, but as proving that they were not mistaken in supposing that the profession 
elt the need of and would generously support a weekly journal, national in the fullest 
jense of the word, devoted to the best interests of medical science, and conducted with 
the forethought, energy and ability necessary to devise and execute every available 
plan for enhancing its usefulness. Encouraged by this approbation, renewed efforts 
will be made during 1883 by those in charge of The News to strengthen in every way 



2 Henry C. Lea's Son & Co.'s Publications — ( The Medical Xeirs). 

its hold upon the respect and esteem of the profession. Advocating the highest stand- 
ard of morals and honor, The News will be an unsparing opponent of quackery, in its 
countless forms. As the recognized national organ of the regular profession, it is the 
D vehicle for the conveyance of the most important intelligence from all parts of 
the country. 

The general plan of The News affords ample space for the presentation of articles 
upon all branches of medical science. The opening pages are devoted to Original 
Lrctctrks by the ablest teachers of the day, which are invariably revised by their au- 
thors before publication, thus insuring an authenticity and exactitude otherwise unat- 
tainable. In the department of Original Articles, The News will endeavor, as here- 
tofore, to surpass its contemporaries, both in the intrinsic value of the contributions 
and in the reputation of their authors. Under the caption of Hospital Notes is laid 
open the vast and rich store of clinical information developed in the chief hospitals of 
the globe. The department of Medical Progress consists of condensations of articles 
of importance appearing in the leading medical, pharmaceutical, and scientific journals 
of the world. The Kditorial Articles are from the pens of a large and able Edi- 
torial Board, and discuss living subjects in all departments of medical science in 
a thoughtful, independent and scholarly manner. Important subjects, requiring un. 
usually elaborate c> nsideration, are treated in Special Articles. The Proceedings of 
Societies in all parts of the country afford a means of imparting valuable information, 
for which due space is reserved. For the collection of News Items, and for Correspond- 
ence, The News enjoys an organization similar to that of a daily newspaper, and by 
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correspondents, located in the following cities : In the United States : Portland, Boston. 
New York, Baltimore, Pittsburgh, Washington, Charleston, New Orleans, Cincinnati, 
Chicago, Detroit, Kansas City and San Francisco. In Canada: Montreal. In Great 
Britain: London and Edinburgh. In Continental Europe: Paris, Berlin, Yienna and 
Florence. In Asia : Yokohama, Canton, Hong Kong and Calcutta. In South Amer- 
ica : Bio Janeiro and Yalparaiso. In Cuba : Havana. Due attention will be paid to 
New Publications, New Instruments and New Pharmaceutical Preparations, and 
a column will be devoted to Notes and Queries. Space is reserved each week for accu- 
rate reports of all changes in the Army and Navy Medical Service. 

The Medical News will appear in a double-columned quarto form, printed by the 
latest improved Hoe speed presses, on handsome paper, from a clear, easily read type, 
specially cast for its use. 

It will thus be seen that The Medical News employs all the approved methods of 
modern journalism in its efforts to render itself indispensable to the profession, and in 
the anticipation of an unprecedented circulation, its subscription has been placed at 
the exceedingly low rate of $5 per annum, in advance. At this rate it ranks as the 
cheapest medical periodical in the world, and when taken in connection with the Amer- 
ican Journal at NINE DOLLARS per annum, it is confidently asserted that a larger 
amount of material of the highest class is offered than can be obtained elsewhere, even 
at a much higher price. 

THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 

Edited by I. MINIS HAYS, A. M., M. D., 

IS PUBLISHED QUARTERLY, ON THE FIRST DAYS OF JANUARY, APRIL, JULY AND OCTOBER, 
EACH NUMBER CONTAINING OVER THREE HUNDRED OCTAVO PAGES, FULLY ILLUSTRATED. 

In commencing the sixty-fourth cousecutive year of the publication of the American 
Jocrnal, the publishers announce, with no little pride, that its prospects of continued 
usefulness and attractiveness never were brighter. Being the only periodical in the 



Henry C. Lea's Son & Co.'s Publications — (Am. journ. Med. Sci.). 3 

English language capable of presenting extensive and elaborate articles — the form 
in which the most important discoveries have always been communicated to the pro- 
fession, The American Journal cannot fail to be of the utmost value to physicians 
who would keep themselves au courant with the medical thought of the day. It may 
justly claim that it numbers among its contributors all the most distinguished members 
of the profession, that its history is identified with the advances of medical knowledge, 
and that, its circulation is co-extensive with the use of the English language. 

During 1883 The Journal will continue to present those features which have long 
proved so attractive to its readers. 

The Original Department will consist of elaborate and richly illustrated articles 
from the pens of the most eminent members of the profession in all parts of the country. 

The Review Department will maintain its well-earned reputation for discernment 
and impartiality, and will contain elaborate reviews of new works and topics of the 
day, and numerous analytical and bibliographical notices by competent writers. 

Then follows the Quarterly Summary of Improvements and Discoveries in the 
Medical Sciences, which, being a classified and arranged condensation of important 
articles appearing in the chief medical journals of the world, furnishes a compact 
digest of medical progress abroad and at home. 

The subscription price to the American Journal of the Medical Sciences has 
never been raised during its long career. It is still sent free of postage for Five Dollars 
per annum in advance. 

Taken together the Journal and News combine the advantages of the elabo- 
rate preparation that can be devoted to a quarterly, with the prompt conveyance of 
intelligence by the weekly ; while, by special management, duplication of matter is ren- 
dered impossible. 

It will thus be seen that for the very moderate sum of NINE DOLLARS in advance 
the subscriber will receive free of postage a weekly and a quarterly journal, both repre- 
senting the. most advanced condition of the medical sciences, and containing an equiva- 
lent of more than 4000 octavo pages, stored with the choicest material, original ami 
selected, that can be furnished by the best medical talent of both hemispheres. It would 
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Gentlemen desiring to avail themselves of the advantages thus offered will do well to 
forward their subscriptions at an early day, in order to insure the receipt of complete 
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tions may be made at the risk of the publishers by forwarding in registered letters. 
Address, 

Henry C. Lea's Son & Co., Nos. 706 and 708 Sansom St., Philadelphia, Pa. 

* # * Communications to both these periodicals are invited from gentlemen in all 
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will be furnished without cost to the author. 

All letters pertaining to the Editorial Department of The Medical News and 
The American Journal op the Medical Sciences should be addressed to the 
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All letters pertaining to the Business Department of these journals should be addressed 
exclusively to Henry C. Lea's Son & Co., 706 and 708 Sansom Street, Phila., Pa. 



Henry C. Lea's Son & Co.'s Publications — (Dictionaries). 



riDXGLlSON (ROBLEY), M.D., 

U Lot- Professor of TntHtvtet of M dicini in Jefferson Medical College, Philadelphia. 

MEDICAL LEXICON; A Dictionary of Medical Science: Con- 
taining a concise explanation of the various Subject? and Term? of Anatomy, Physiology, 
Pathology, Hygiene, Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medical 
Jurisprudence and Dentistry. Notices of Climate and of Mineral Waters; Formulae for 
Officinal, Empirical and Dietetic Preparation? ; with the Accentuation and Etymology of 
the Terms, and the French and other Synonymes ; so as to constitute a French as well as an 
English Medical Lexicon. A New Edition, thoroughly Revised, and very greatly Mod- 
ified and Augmented. By RlCHARD J'. Dtwo lison, M.D. In one very large and hand- 
some royal octavo volume of over 1 1(1(1 pages. Cloth. $6 50 ; leather, raised bands, $7 50; 
very handsome half Russia, raised bands, $8. 
The object of the author from the outset has not been to make the work a mere lexicon or 
dictionary of terms, but to afford, under each, a condensed view of its various medical relations, 
and thus "to render the work an epitome of the existing condition of medical science. Starting 
with this view, the immense demand which has existed fort he work has enabled him, in repeated 
revisions, to augment its completeness and usefulness, until at length it has attained the position 
of a recognized and standard authority wherever the language is spoken. 

Special pains have been taken in the preparation of the present edition to maintain this en- 
viable reputation During the ten years which have elapsed since the last revision, the additions 
tothenoinenjlatureofthemedic.il sciences have been greater than perhaps in any similar period 
of the past, and up to the time of his death the author labored assiduously to incorporate every- 
thing rehiring the attention of the student or practitioner. Since then, the editor has been 
eiiuallyindustrious, so that the additions to the vocabulary are more numerous than in any pre- 
viriis revision. Especial attention ha- been bestowed on the accentuation, which will be found 
marked on every word. The typographical arrangement has been much improved, rendering 
reference much more easy, and every care has been taken with the mechanical execution. The 
work has been printed from new type, small but exceedingly clear, with an enlarged page, so 
that the additions have been incorporated with an increase of but little over a hundred pages, 
and the volume now contains the matter of at least four ordinary octavos. 

A book well known to our readers, and of which 
every American ought to be proud. When the learned 
author of the work passed away, probably all of us 
feared lest the book should not maintain its place 
in the advaucing science whose terms it defines. For- 



tunately, Dr. Kictiard .J. Duuglison, having assisted bis 
father in the revision of several editions of the work, 
aad having been, therefore, trained in the methods and 
imbued with the spirit of the book, has been able to 
sdit it. not in the patchwork manner so dear to the 
Ueart of book editors, so repulsive to the taste of intel- 
book reader.-, but to edit it as a work of the kind 
suouldbe edited — to carry it on steadily, without jar 
or interruption, along the grooves of thought it has 
travelled dunug its lifetime. To show the magnitude 
of the task which Dr. Dunglison has assumed and car- 
ried through, it is only necessary to state that more 
than six thousand new subjects have been added in the 
present edition. — Phila.Merl. Times. Jan 3, 1874. 

About the tirst book purchased by the medical stu- 
lentis the Medical Dictionary. The lexicon explana- 
tory of technical terms is simply tisine qua non. In a 
science so extensive, and with such collaterals as medi- 
cine, it is as much a necessity also to the practising 
physician. To meet the wants of students and most 
physicians, the dictionary must be condensed while 
comprehensive, and practical while perspicacious. It 
was because Duuglison's met these indications that It 
became at once the dictionary of general use wherever 
medicine was studied in the English language. In no 
former revision have thealterations and additions been 
so great. More t ban six thousand new subjects and t arm* 
•en added. The chief terms have been set in black 
letter, while the derivatives follow in small caps; an 
arrangement which greatly facilitates reference. We 



may safely confirm the hope ventured by the editor 
■' that the work, which possesses for him a filial as well 
as an individual interest, will be found worthy a con- 
tinuance of the position so long accorded to it as a 
standard authority ."—Cincinnati Clinic, Jan. 10. 1874. 
It has the rare merit that it certainly has no rival 
in the English language for accaracyandex'ent of 
references. — London Medical Gazette . 

As a standard work of reference, as one of the best, 
if not the very best, medical dictionary in the Eng- 
lish language, Dunglison's work has been well known 
for about forty years, and needs no words of praise 
on onr part to recommend it to the members of the 
medical, and, likewise, of the pharmaceutical pro- 
fession. The latter especially are in need of such a 
work, which gives ready and reliable information 
on thousands of subjects and terms which they are 
liable to encounter in pursuing their daily avoca- 
tions, but with which they cannot be expected to be 
familiar. The work before us fully supplies this 
want. — Am. Journ. of Pharm., Feb. 1874. 

A valuable dictionary of the terms employed in 
medicine and the allied sciences, and of the rela- 
tions of the subjects treated under each head. It re- 
flects great credit on its able American author, and 
well deserves the authority and popularity it has 
obtained.— British Med. Journ., Oct. 31, 1874. 

Few works of this class exhibit a grander monu- 
ment of patient research and of scientific lore. The 
extent of the sale of this lexicon is sufficient to tes- 
tify to its usefulness, and to the great service con- 
ferred by Dr. Robley Dunglison on the profession, 
and indeed on others, by its issue. — London Lancet , 
May IS, 1875. 



UOBLTN (RICHARD D.), M.D 

A DICTIONARY OF THE TERMS USED IN MEDICINE AND 

TIIE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hays, 
M.D.,late Editor of The American Journal of the Medical Sciences. In one large 
royal 12mo. volume of 520 double-columned pages. Cloth, $1 50 ; leather, $2 00 
It la the best book of definitions we have, and ought always to be upon the student's table.— Southern 
Med. and Surg Journal. 

OD WELL (G. F.), F.R.A.S., frc. 

A DICTIONARY OF SCIENCE: Comprising Astronomy, Chem- 
istry, Dynamics, Electricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, 
Mechanics, Meteorology, Pneumatics, Sound and Statics. Preceded by an Essay on the 
History of the Physical Sciences. In one handsome octavo volume of 694 pages, with 
many illustrations. Cloth, $5. 



R 



Henry C. Lea's Son & Co.'s Publications — (Manuals). 



A CENTURY OF AMERICAN MEDICINE, 1776-1876. By Doctors E. H. 
■*■*■ Clarke, H- J. Bigelow, S. D. Gross, T. Q. Thomas andJ. S. Billings. Inone very hand- 
some 12mo. volume of about 350 pages. Cloth, $2 25. 

This work appeared in the pages of the American Journal of the Medical Sciencesduring the 
year 1876. As a detailed account of the development of medical science in America, by gentle- 
men of the highest authority in their respective departments, the profession will no doubt wel- 
come it in a form adapted for preservation and reference. 



■XTEILL {JOHN), M.D., and VMITH {FRANCIS G.), M.D., 

"*~ Prof, of the Institutes of Medicine inthe Univ. of Penna 

AN ANALYTICAL COMPENDIUM OF THE VARIOUS 

BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A 
New Edition , revised and improved. In one very large and handsomely printed royal 12mo. 
volume, of 974 pages, with 374 wood-cuts. Cloth, $4 ; strongly boundin leather, with 
raised bands, $4 75. 



TJARTSHORNE {HENRY), M.D., 

■*"*- Late Professor of Hygiene in the University of Pennsylvania. 

A CONSPECTUS OF THE MEDICAL SCIENCES; containing 

Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, 
Surgery and Obstetrics. Second Edition, thoroughly revised and greatly improved. In 
one large royal 12mo. volume of 1028 closely printed pages, with 477 illustrations on 
wood. Cloth, $4 25 ; leather, $5 00. 



We can say with the strictest truth that it is the 
best work of the kind with which we areacquainted. 
It embodies ina condensed form all recent contribu- 
tions to practical medicine, and is therefore useful 
to every busy practitioner throughout our country, 
besides being admirably adapted to the use of stu- 
dents of medicine. The book is faithfully and ably 
executed. — Charleston Med. Journ., April, 1875. 

The work is intended as an aid to the medical 
student, and as such appears to fulfil admirably its 
object by its excellent arrangement, the full compi- 
lation of facts, the perspicuity and terseness of lan- 
guage, and the clear and instructive illustrations 
in some parts of the work. — American Journ. of 
Pharmacy, Philadelphia, July, 1874. 

The volume will be found useful, not only to stu- 
dents, but to many otherswhomay desire torefresh 
their memories with the smallest possible expendi- 
ture of time.— N. Y. Med. Journal, Sept. 1874. 

The student will find this the mostconvenient and 
useful book of the kind on which he can lay his 
hand. — Pacific Med. and Surg. Journ., Aug. 1874. 

This is the best book of its kind that we have ever 
examined. It is an honest, accurate and concise 
compend of medical sciences, as fairly as possible 
representing their present condition. The 
and the additions have been so judicious and t 



worthy. If students must have a conspectus, they 
will be wise to procure that of Dr. Hartshorne.— 
Detroit Rev. of Med. and Pharm., Aug. 1874. 

The work before us has many redeeming features 
not possessed by others, and is the best we have 
seen. Dr. Hartshorne exhibits much skill in con- 
densation. It is well adapted to the physician in 
active practice, who can give but limited time to the 
familiarizing of himself with the important changes 
which have been made since he attended lectures. 
The manual of physiology has also been improved 
and gives the most comprehensive view of the latest 
advances in the science possible in the space devoted 
to the subject. The mechanical execution of the 
book leaves nothing to be wished for.— Peninsular 
Journal of Medicine, Sept. 1874. 

After carefully looking through this conspectus, 
we are constrained to say that it is the most com- 
plete work, especially in its illustrations, of its kind 
that we have seen.— Cincinnati Lancet, Sept. 1874. 

The favor with which the first edition of this 
Compendium was received, was an evidence of its 
various excellences. The present edition bears evi- 
dence of a careful and thorough revision. Dr. Harts- 
horne possesses a happy faculty of seizing upon the 
salientpointsof each subject, and of presenting them 
- - concise and yet perspicuous manner.— Lmven- 



rough as to render it, so far as it goes, entirely trust- 1 worth Med. Herald, Oct. 1874. 



T UDLO W {J. L.), M.D. 
A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 

Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and 
Therapeutics. To which is added a Medical Formulary. Third Edition, thoroughly revised 
and greatly extended and enlarged. In one handsome rcyal 12mo. volume of 816 
large pages, with 370 illustrations. Cloth, $3 25 ; leather, $3 75. 
The arrangement ofthis volume in the form of question andanswer renders it especially suit- 
able for the office examination of students, and for those preparing for graduation. 



WANNER {THOMAS HAWKES), M.D., frc. 
■ A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- 

NOSIS. Third American from the Second London Edition. Revised and Enlarged by 
Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, 
London, &c. In one small 12mo. volume of about 375 pages. Cloth, $1 50. 



SEAEPEY AND QDAIN'S HUMAN ANATOMY. , HEATH'S PRACTICAL ANATOMY. From Second 
Revised by Joseph Lefdy, M.D., Prof of Anat. in London Edition, with additions by W W. Keen, 
Univ. of Penn In two octavo vols; of about 1300 M.D. In one 12mo. volume of 578 pages, with 247 
pages, with 511 illustrations. I woodcuts. 



6 Henry C. Lea's Son & Co.'s Publications— (Anatomy). 

67 RAY {HENRY), F.R.S., 
T Lecturer on Anatomy at St. George's Hospital, London. 

ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by 

H. V. Carter, M.D., and Dr. Wkstmacott. The Dissections jointly by the AuTHORan,d 
Dr. Carter. With an Introduction on General Anatomy and Development by T. 
Holmes, M.A., Surgeon to St. George's Hospital. A New American, from the Eighth 
Eolargedand Improved London Edition. To which is added the Second American from the 
latest English Edition of " LANDMARKS, Medical and Surgical," by Luther Holder, 
F.K.C.S., author of "Human Osteology," "A Manual of Dissections," etc. In one 
magnificent imperial octavo volume of 993 pages, with 523 large and elaborate engrav- 
ings on wood. Cloth, $6; leather, raised bands, $7 ; half Russia, raised bands $7 5u. 
The author has endeavored in this work to cover a more ex tended ranged subjects than is cus- 
tomary in the ordinary text-books, by giving not only the details necessary for the student, but 
also the application of those details in the practice of medicine and surgery, thus rendering it both 
a guide for the learner and an admirable work of reference for the active practitioner. The en- 
gravings form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in place of 
figures of reference, with descriptions at the foot. They thus form a completeand splendid series, 
waich will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve tc 
rsfresh the memory of those who may find in the exigencies of practice the necessity of recalling 
the details of the dissecting room. Combining, as it does, a complete Atlas of Anatomy, with 
a thorough treatise on systematic, descriptive and applied Anatomy, the work will be found of 
great service to all physicians who receive students in their offices, relieving both preceptor and 
pupil of much labor in laying the groundwork of a thorough medical education. 

To the present edition has been appended the recent work by the distinguished anatomist, 
Mr. Luther Holden — "Landmarks, Medical and Surgical' — which gives in a clear, condensed 
and systematic way, all the information by which the practitioner can determine from the ex- 
ternal surface of the body the position of internal parts. Thus complete, the work, it is believed, 
will furnish all the assistance that can berendered by typennd illustration in anatomical study. 
Notwithstanding the increase of size, amounting to over 100 pages and 57 illustrations, it will 
be kept, as heretofore, at a price rendering it one of the cheapest works ever offered to the 
American profession. 

The addition of the recent work of Mr. Holden, i any branch of medical science. The labors of the 
as an appendix, renders this the most practical and eminent men who have successively revised the 
complete treatise available to American students, eight editions through which it has passed, would 
who find in it a comprehensive chapter on minnte seem to leave nothing for future editors to do. The 
anatomy, about all that can be taught on general addition of Holden's " Landmarks" will make it as 
aud special anatomy, while its treatment of each indispensable to the practitioner of medicine aud 
region, from a surgical point of view, in the vain- surgery as it has been heretofore to the student. As 
able section by Mr. Holden, is all that will beessen- regards completeness, ease of reference, utility, 
tial to them in practice.— Ohio Medical Recorder, beauty and cheapness, it has no rival. No stft- 
Aag 167S. d-^nt should enter a medical school without it ; no 

It is difficult to speak in moderateterms of thi? physician can afford to have it absent from his 
new edition of "Gray." It seems to be as nearft Hbrary.-tt. Louis Clin. Record, Sept. 1878. 
perfect as it is possible to make a book devoted to , 
Also for sale separate — 
TTOLDEN [LUTHER), F.R.C.S., 

JLJL Surgeon to St. Bartholomew's and the Foundling Hospitals. 

LANDMARKS, MEDICAL AND SURGICAL. Second American, 

from the Latest Revised English Edition, with additions by W. W. Keen, M.D., Profes- 
sor of Artistic Anatomy in the Pennsylvania Academy of the Fine Arts, formerly Lec- 
turer on Anatomy in the Philadelphia School of Anatomy. In one handsome 12nio. 
volume, of about 140 pages. Cloth, $1.00. (Just Ready.) 



This little book is all that can be desired within 
its scope and its contents will be found simply in- 
valuable to the young surge >n or physician, since 
they bring be'ore him such data as he requires 



this little volume, will refrain from purchasing it. 
It teaches diagnosis by external examination, ocu- 
lar and palpaDle, of the body, with such anatomi- 
1 and physiological fact6 as directly bear on th 



„.ery examination of a patient. It is written in subject. It is eminently the student's and young 
language so clear and concise that one ought almost | practitioner's book.— Physician and Surgeon, Nov. 
to learn it by heart. No student, once he has seen i 1S81. 

<JM1TH {HENRY H.), M.D., arift TJORNER { WILLIAM E.),M.D., 

Prof '.of Surgery in the Univ.of Penna.,Ac. • Late Prof . of Anatomy in the Univ. ofPenna. 

AN ANATOMICAL ATLAS ; Illustrative of the Structure of the 

Human Body. In one volume, large imperial octavo, cloth, with about six hundred and 
fifty beautiful figures. $4 50. 

BELLAMYS STUDENT'S GUIDE TO SURGICAL , HARTSHORNE'S HANDBOOK OF ANATOMY AND 



I ATOMY : A Text-book for Students preparing 
for their Pass Examination. With engravings on 
wood. In one royal 12mo. volume. Cloth, *2 25. 
CLKLAND'S DIRECTORY FOR THE DISSECTION 
OF THE HUMAN BODY. In one small volume, 
royal 12mo. of 182 pages. Cloth, f 125. 



PHYSIOLOGY. Second Edition, revised. In 
royal 12mo. vol., with 220 woodcuts. Cloth,$l 
SORNER'S SPECIAL ANATOMY AND HISTOL- 
OGY. Eighth Edition, extensively revised and 
modified. In 2 vols. Svo., of over 1000 pages, 
with 32) wood-cuts. Cloth, $6 00. 



Henry C. Lea's Son & Co.'s Publications — (Anatomy). 1 

A LLEN (HARRISON), M.D. 

***- Professor of Physiology in the Univ. of Pa. 

A SYSTEM OF HUMAN ANATOMY: INCLUDING ITS MEDICAL 

and Surgical Relations. For the Use of Practitioners and Studentsof Medicine. With an 
Introductory Chapter on Histology. ByE. 0. Shakespeare, M D ., Ophthalmologistto the 
Phila. Hosp. In one large and handsome quarto volume of about 600 doubli-columDed 
pages, with 380 illustrations on 109 lithographic plates, many of which are in colors, 
and about 250 engravings in the text. In six Sections, each in a portfolio. Section I. 
Histology (Just Ready). Section II. Bones and Joints {Just Ready). Section III. 
Muscles and Fascia (Just Ready) . Section IV. Artkries, Veins and Lymphatics 
(Nearly Ready.) Section V. Nervous System (In Press). Section VI. Organs of 
Sense, op Digestion and Genito-Urinary Organs (In Press). Price per section, 
$3 50. For sale by subscription only. 

EXTRACT FROM INTRODUCTION. 

It is the design of this book to present the facts of human anatomy in the manner best suited 
to the requirements of the student and the practitioner of medicine. The author believes that 
such a book is needed, inasmuch as no treatise, as far as he knows, contains, in addition to the 
text descriptive of the subject, a systematic presentation of such anatomical facts as can be applied 
to practice. 

A book which will Veat once accurate in statement and concise in terms ; whioh will be an 
acceptable expression of the present state of the science of anatomy ; which will exclude nothing 
that can be made applicable to the medical art, and which will thus embrace all of surgical im- 
portance, while omitting nothing of value to clinical medicine, — would appear to have an excuse 
for existence in a country where most surgeons are general practitioners, and where there are 
few general practitioners who have no interest in surgery. 

Among other matters, the book will be found to contain an elaborate description of the tis- 
sues ; an aecount of the normal development of the body ; a section on the nature and varieties 
of monstrosities ; a section on the method of conducting post-mortem examinations ; and a sec- 
tion on the study of the superficies of the body taken as a guide to the position of the deeper 
structures. These will appear in their appropriate places, duly subordinated to the design of 
presenting a text essentially anatomical. 

A book like this is au ideal rarely realized. It j It is to be considered a study of applied anatomy 
will do, we have no doubt, what its accomplished i in its widest sense — a systematic presentation of 
author hopes, "make anatomy- what unfortunately [ such anatomical facts as can be applied to the prac- 
it rarely is — an interesting study." It has long tice of medicine as well as of surgery. Our author 



been an opprobrium to America that our anat imical 
text-books were all foreign, but thia woik will re- 
move the stigma. It is a mine of wealth io the in- 
formation it gives. It differs from all preceding 
anatomies in its scope, and is, we believe, a vast 
improvement upon them all. The chief novelty 
about the book, and really one of the greatest needs 
in anatomy, is the extension of the text to cover not 
only anatomical descriptions, but the rises of anato- 
my in studying disease. This is done by stating the 
narrower topographical relations, and also the wider 
clinical relations of the more remute parts, by giving 
a brief account of the uses of the various organs, and 
by quoting cases which illustrate the "localization of 
diseased action." Dr. Shakespeare has furnished the 
Section on Histology, and it is well done. The Sec- 
tion on the Bones and Joints shows on every page 
evidences of Dr. Allen's wide learning and judicious 
selection of material, embarrassing by its very rich- 
ness. The plates are beautiful specimens of work 
by one who long since won a deserved reputation an 
an artist.— The Medical News, October 21, 1882 



cise, accurate and practical in his statements, 
and succeeds admirably in infusing an interest into 
the study of what is generally considered a dry 
subject. The department of Histology is treated ia 
a masterly manner, and the ground is travelled 
over by one thoroughly familiar with it. The illus- 
trations are made with gieat care, and are simply 
superb. It would be impossible, except in a gene- 
ral way, to point out the excellence of the work of 
the author in the second section, that devoted ;o 
the consideration of the Bones and Joints. There 
is as much of practical application of anatomical 
points to the every-day wants of the medical clini- 
cian as to those of the operating surgeon. In fact, 
few general practitioners will read the work with- 
out a feeling of surprised gratification that so many 
points concerning which they may never have 
thought before are so well presented for their con- 
sideration. It is a work which is destined to be 
the best of its kind in any language. — Medical 
Record, Nov. 23, 1S82. 



TfLLIS (GEORGE V1NER). 

■U Emeritus Professor of Anatomy in University College, London. 

DEMONSTRATIONS OF ANATOMY ; Being a Guide to the Know- 

ledge of the Human Body by Dissection. By George Viner Ellis, Emeritus Professor 
of Anatomy in University College, London. From the Eighth and Revised London Edi- 
tion. In one very handsome octavo volume of over 700 pages, with 249 illustrations. 
Cloth, $4.25 ; leather, $5.25. 



Ellis' Demonstrations is the favorite text-book 
of the English student of anatomy. In passrug 
through eight editions it has been so revised and 
adapted to the needs of the student that it would 
seem that it had almost reached perfection in this 
special line. The descriptions are clear, and the 
methods of pursuing anatomical investigations are 
given with such detail that the book is honestly 
entitled to its name.— Si. Louis Clinical Record, 
Jone, 1879. 



As a dissector, or a work to have in hand and 
study while one is engaged in dissecting, we re- 
gard it as the very best work extant, which is cer- 
tainly saying a very great deal. As a text-book to 
be studied in the dissecting-room, it is superior to 
any of the works upon anatomy. — Cincinnati Med. 
News, May 24, 1879. 

We most unreservedly recommend it to every 
practitioner of medicine who can possibly get it — 
Va. Med. Monthly, June, 1879. 



w 



ILSON (ERASMUS), F.R.S. 

A SYSTEM OF HUMAN ANATOMY, General and Special. Edited 

by W. H. Gobrecht, M.D., Professor of General and Surgical Anatomyin the Medical Col- 
lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood . In 
one large and handsome octavo volume, of over 600 pages. Cloth, $4 ; leather, $5. 



Henry C. Lea's Son & Co.'s Publications — (Physiology). 



n ALTON {JOHN C), M.D., 

■IS Prof 'essor of Physiology in the College of Physicians and Surgeons, Nets York, Ac. 

A TREATISE ON HUMAN PHYSIOLOGY. Designedfortheu.se. 

of Students nnd Practitioners of Medicine. Seventh Edition, thoroughly revised and rewrit- 
ten. In one very beautiful octavo volume, of 722 pages, with 252 beautiful engravings 
on wood. Cloth, $5 00; leather, $6 00; very handsome half Russia, raised bands, $6 50. 
(Just R 
The reputntion which this work has acquired, as a compact and convenient summary of the 
most advanced condition of human physiology, renders it only necessary to state that the au- 
thor has assiduously labored to render the present edition worthy a continuance of the marked 
favor accorded to previous issues, and that every care has been bestowed upon the typographi- 
cal execution to make it, as heretofore, one of the handsomest productions of the American press. 
The meritsof Prof. Dalton'e tezl book, hie emoo b clearer and more attractive light. A most every page 
aud pleasing style, the remarkable cHarress of bin bears evideuce of the exhaustive revision that has 
descriptions, which leave not a chapter obscure, taken place. The material is placed in a more com- 



his cautious judgment and the general correctness 
of hie facts, are perfectly known. They have made 
his text-book the one most familiar, perhaps, to 
American students. — Med. Record, March 4, 1882. 

This very popular work appears in its present 
edition somewhat diminished in size from conden- 
sation of certain sections, but increased in availa- 
bility for every-day use. It has undergone very 
close revision, and expounds the science np to the 
latest discoveries. The author, as in former edi- 
tions, serves his material In highly assimilable 
style. — Louisville Med. Nfws, Feb. 25, 16S2. 

Certainly no physiological work has ever issued 
from the press that presented its subject matter in a 



pact form, yet its de i-htful charm is retained, aud 
no subject is thrown into obscurity. Altogether this 
edition is far iu advance of any previous one, .ind 
will tend to keep the profession posted as to the most 
recent additions to our physiological knowledge. — 
Michigan Medical News, April, 1SS2. 

This text-book of physiology has always been a 
great favorite. The clear descriptions, the easy 
mode of writing, the handsome black-ground wood- 
cuts, have each had their share in winning this pop- 
ularity. That it has now reached its seventh edition 
is proof enough of the value placed upon it by ti e 
profession. — Canada Medical and Surgical Jour- 
nal, June, 1S82. 



(1AKPENTER { WILLIAM B.), M.I)., F.R.8., F.G.S., F.L.S., 

^ Registrar to University of London, etc. 

PRINCIPLES OF HUMAN PHYSIOLOGY; Edited by HenryPower, 

M.B. Lond., F.R.C.S., Examinerin Natural Sciences, University of Oxford. A New 
American from the Eighth Revised and Enlarged English Edition, with Notes and Addi- 
tions, by Francis G.Smith, M.D., Professor ol thelnstitutesof Medicinein the Univer- 
sity of Pennsylvania, etc. In one very large and handsome octavo volume, of 1083 pages, 
with two plates and 373 engs. on wood. Cloth, $5 50; leather, $6 50 ; half Russia, $7. 



We have been agreeably surprised to find the vol 
nme so completein regard to the structure and func- 
tions of the nervous system in all its relations, a 
subject that, in many respects, is one of the most diffi- 
cult of all, in the whole range of physiology, upon 
which to produce a full and satisfactory treatise of 
the class to which the one before us belongs. The 
additions by the American editor give to the work as 
It is a considerable value beyond that of the last 
Euglish edition. In conclusion, we can give ourcor- 
dJal recommendation to the work as it now appears. 
The editors have, with their additions to the only 
work on physiology in our language that, in the full- 
est sense of the word, is the production of a philoso- 
pher aswell as a physiologist, brought it up as fully 
as conld be expected, if not desired, to the standard 
of our knowledge of its subject at the present day. 
It will deservedly maintain the place it has always 
had in the favor of the medical profession. — Joum. 
of Nervous and Mental DUease, April, 1877. 

Such enormousadvances haverecentlybeenmadein 
our physiological knowledge, that what was perfectly 



new a year or two ago. looks now as if It had been a 
received and established fact for years. In this ency- 
clopaedic way this work is unrivalled. Here, as it seems 
to us, is the great value of the book; one is safe in send- 
ing a student to it for information on almost any given 
subject, perfectly certain of the fulness of information 
it will convey, and well satisfied of the accuracy with 
which it will there be found stated.— London Med. 
Ttvies and Gazette, Feb. 17, 1877. 

The meritsof "Carpenter's Physiology" are so widely 
known and appreciated that we need only allude briefly 
to the fact that in the latest edition will be found a com- 
prehensive embodiment of the results of recent physio- 
logical investigation. Care has been taken to preserve 
the practical character of the original work. In fact 
the entire work has been brought up to date, and bears 
evidence of the amount of labor that has been bestowed 
upon it by its distinguished editor, Mr. Henry Power. 
The American editor has made the latest additions, in 
order fully to cover the time that has elapsed since the 
last English edition.— A". T. Med. Journal, Jan. 187 7. 



10STER {MICHAEL), M.D., F.R.S., 

Professor of Physiology in Cambridge University, England. 

TEXT-BOOK OF PHYSIOLOGY. Second American from the Latest 

English Edition. Edited, with Extensive Notes and Additions, by Edward T. Reichert, 
M.L>., Late Demonstrator of Experimental Therapeutics in the University of Pennsylva- 
nia. In one handsome royal 12mo. volume of about 1000 pages, with 259 illustrations. 
Cloth, $3 25 ; leather, $3 75. (Just Issued.) 

long hold its place as a standard text-book on phy- 
siology — Phila. Med. and Surg Reporter, NoV. 



It is a pleasing sign to observe the appreciation 
a! so thoroughly scientific a work asFoster's " Phy- 
siology" by the American student, an appreciation 
which is amply proven by the fact of the exhaus- 
tion of the first American edition within a twelve- 
month. In its present shape, the work will be 
found thoroughly up to the times, recent advances 
iu physiology having been duly noticed by the 
American editor.— Med. Record, Nov. S6, 1SS1. 

The first American edition having been exhausted 
in the short period of one year, the editor has avail- 
ed himself of the opportunity to revise carefully the 
material added to the text of the former edition, ami 
to make such additions as recent advances in ex- 
perimental phvsiology call for. This w.urfc wil l 
CARPENTER'S PRIZE ESSAY ON THE USE AND 

ABCSE OF ALCOHOLIC LlQCORS IN HEALTH AND DIS- 
EASE. New Edition, with a Preface by D. F. Con- 



26, isai 

The readers ot the former American edition will 
doubtless agree that there is no better textbook on 
physiology than this, in print. Besides being clear 
and simple in its statements, it is abreast with the 
very latest researches, and these are presented iu 
a n instructive, and. indeed, in an entertaining style. 
A most admirable work, this new edition ot it will 
prove acceptable, not only to younger students, 
but also to physicians who still wish to base their 
treatment of rhe abnormal on a knowledge of nor- 
mal conditions of the body. — Buffalo Med. and 
S'irg. Joum., Dec 1881, 

die. M D., and explanations of scientific words. 

In one small 12mo. volume of 178 pages. Cloth, 

60 cents. 



Henry C. Lea's Son & Co.'s Publications — (Chemistry). 9 

A TTFIELD {JOHN), Ph.D., 

■*-*- Professor of Practical Chemistry to the Pharmaceutical Society of Qreat Britain, Sec. 

CHEMISTRY, GENERAL, MEDICAL AND PHARMACEUTICAL ; 

Including the Chemistry of the IT. S. Pharmacopoeia. A Manual of the General Principles 
of the Science, and their Application to Medicine and Pharmacy. Eighth Edition, revised 
bytheauthor. In onehandsonie royall2mo. volume of 701 pages, with 87 illustrations. 
Cloth, $2 50 ; leather, $3 00. 

of chemistry in all the medical colleges in the 
United States. The present edition contains such 



We have repeatedly expressed our favorable 
opinion of this work, and on the appearance of a 
new edition of it, little remains for us to say, ex- 
cept that we expect this eighth edition to be as 
indispensable to us as the seventh and previous 
editions have been. While the general plan and 
arrangement have been adhered to, new matter 
has been added covering the observations made 
since the former edition. The present differs from 
the preceding one chiefly in these alterations and 
in about ten pages of useful tables added in the 
appendix. — Am. Journ. of Pharmacy, May, 1879. 

A standard work like Attfield's Chemistry needs 
only be mentioned by its name, without further 
comments. The present editioD contains such al- 
terations and additions as seemed necessary for 
the demonstration of the latest developments of 
chemical principles, and the latest applications of 
chemistry to pharmacy. The author has bestowed 
arduous labor on the revision, and the extent of 
the information thus introduced may be estimated 
from the fact that the index contains three hun- 
dred new references relating to additional mate- 
rial.— Druggists' Circular and Chemical Gazette, 
May, 1879. 

This very popular and meritorious work has 
now reached its eighth edition, which fact speaks 
in the highest terms in commendation of its excel- 
lence. It has now become the principal text-book 



alterations and additions as seemed necessary for 
the demonstration of the latest developments of 
chemical principles, and the latest applications of 
chemistry to pharmacy. It is scarcely necessary 
for us to say that it exhibits chemistry in its pre- 
sent advanced state. — Cincinnati Medical News, 
April, 1879. 

The popularity which this work has enjoyed is 
owing to the original and clear disposition of the 
facts of the science, the accuracy of the details, and 
the omission of much which freights many treatises 
heavily without bringing corresponding instruction 
to the reader. Dr. Attfield writes for students, and 
primarily for medical students; he always has an 
eye to the pharmacopoeia and its officinal prepara- 
tions ; and he is continnally putting the matter in 
the text so that it responds to the questions with 
which each section is provided. Thus the student 
learns easily, and can always refresh and test his 
knowledge.— Med. andSurg. Reporter, April 19, '79. 

We noticed only about two years and a half ago 
the publication of the preceding edition, and re- 
marked upon the exceptionally valuable character 
of the work. The work now includes the whole of 
the chemistry of the pharmacopoeia of the United 
States, Great Britain and India. — New Remedies. 
May, 1879. 



G 



REENE {WILLIAM H.), M.D., 

Demonstrator of Chemistry in Medical Department, University of Pennsylvania. 

A MANUAL OF MEDICAL CHEMISTRY. For the Use of Students. 

Based upon Bowman's Medical Chemistry. In one royal 12mo. volume of 310 pages, 
with 74 illustrations. Cloth, $1 75. {Just Issued.) 

is well written, and gives the latest views on | The little work before us is one which we think 
vital chemistry, a subject with which most physi- will be studied with pleasure and profit. The de- 
dans are not sufficiently familiar. To those who scriptions. though brief, are clear, and in most cases 
may wish to improve their knowledge in that direc- j sufficient for the purpose. This book will, in nearly 
tion, we can heartily recommend this work as beiDg ' all cases, meet general approval. — Am. Journ. of 
worthy ofacarefulperusal. — Phila. Med. and Surg. \ Pharmacy, April, 1880. 
Reporter, April 24, 1880. I 



S7LASSEN {ALEXANDER), 

^ Professor in the Royal Polytechnic School, Aixla-Chapelle. 

ELEMENTARY QUANTITATIVE ANALYSIS. Translated with 

notes and additions by Edgar F. Smith, Ph.D., Assistant Prof, of Chemistry in the 
Towne Scientific School, Univ. of Penna. In one handsome royal 12ino. volume, of 324 
pages, with 36 illustrations. Cloth, $2 00. 
It is probably the best manual of an elementary advancing to the analysis of minerals and such pro- 
nature extant, insomuch as its methods are the best, ducts as are met with in applied chemistry. It is 
It teaches by examples, commencing with single an indispensable book for students in chemistry.— 
determinations, followed by separations, and then Boston Journal of Chemistry, Oct. 1878. 



fl ALLOW AY {ROBERT), F.C.S., 

^-* Prof of Applied Chemistry in the Royal College of Science for Ireland, etc. 

A MANUAL OF QUALITATIVE ANALYSIS. Prom the Sixth Lon- 

don Edition. In one handsome royal 12mo. volume, with illustrations. {Preparing.) 
T>EMSEN{IRA), M.D., Ph.D., 

Professor of Chemistry in the Johns Bopkins University, Baltimore. 

PRINCIPLES OF THEORETICAL CHEMISTRY, with special reference 

to the Constitution of Chemical Compounds. New Edition. In one handsome royal 
12mo. volume of about 250 pages. (Preparing.) 



BOWMAN'S INTRODUCTION TO PRACTICAL 
CHEMISTRY, INCLUDING ANALYSIS. Sixth 
American, from the Sixth London Edition. In one 
royal 12mo. volume, with illustrations. 

WOHLER AND FITTIG'S OUTLINES OF ORGANIC 
CHEMISTRY. Translated.with additions, from the 
Eighth German Edition. By Ira Remsen. M D., 
Ph.D., Prof, of Chemistry and Physics in Williams 



College, Mass. In one royal 12mo. volume of 559 
pages. Cloth, $3. 

LEHMANN'S MANUAL OF CHEMICAL PHYSIOL- 
OGY. Translated from the German, with Notes 
and Additions, by J. Cheston Morris, M.D. With 
illustrations on wood. In one octavo volume of 
336 pages. Cloth, $2 25. 



10 Henry C. Lea's Son & Co.'s Publications — (Chemistry). 



pOWNES (GEORGE), Ph.D. 

A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and 

Practical. Revised and corrected byHxKHT Watts,B.A.,F R.S., author of "A Diction- 
ary of Chemistry," etc. A New American, from the Twelfth and Enlarged London 
Edition. Edited by Robert Bridges, M.D. In one large royal 12mo. volume, 
of 1031 pages, with 1 77 illustrations and a colored plate. Cloth, $2 75; leather, $3 25. 
This work, inorganic and organic, It complete in what formidable magnitude with its more than a 
)ne convenient volume. In it* earliest edition I il thousand pages, but with less than thin no fair repre- 
iras fully up lothe latent advancements and then- Mentation of cheiuistryas it now iscan begiven. The 
In its present form, it presents, type is small but very clear, and the section* are very 
lucidly arranged to facilitate study and reference.— 



bat time. In its present fo 
In a remarkably convenient and satisfactory man- 
ner, the principles and leading facts of the chemistry 
of to-day. Concerning the manner in which the 
Various inbjectS are treated, imicli de-erven to be 
said, and mostly, too, in praise of the book. Are- 
ten ■ work as Fbtones' chemistry within 
t lie limits of a book-notice for a medical weekly is 



.Wd. and Surg. Reporter, Aug 3, 1*7 

The work is too well known to American students 
to need any extended notice; suffice it to say that 
the revision by the English editor has been faithfully 
done, and that Professor Bridges has added some 
fresh and valuable matter, especially in the inor- 



sirnply out oft he question. —Cincinnati Lancet and j ga nic chemistry. The book has always been a fa- 
Cfinic, Dec. 14, 1878. | vorite in this country, and in its new shape bids 

When we state that, in our opinion, the present fair to retain all its former prestige. — Boston Jour. 
e lltlon * n- tains iu every respect tte high reputation of Chemistry, Aug. 187S. 

It will be entirely unnecessary for us to make any 



which its predecessors have acquired and enjoyed, 
we express therewith our full belief in its intrinsic 
value as a text-book and work of reference. — Am. 
/ r/i.irm., Aug. 1878. 
The conscientious care which has been bestowed 
upon it by the American and Euglish editors renders 
it still, perhaps, the best book for the student and the 
practitioner who would keep alive the acquisitions 
of his student days. It has, indeed, reached a some- 



remarks relating tothe general characterof Pownes' 
Manual. For over twenty years it has held the fore- 
most place as a text-book, and the elaborate and 
thorough revisions which have been made from tim6 
to timeleavelittlechance for any wide a wake rival to 
step before It. — Canadian Phnrm. Jour., Ang. 1S7S. 
As a manual of chemistry it is without a superior 
in the language.— Md. Med. Jour., Aug. 1S78. 



£ 



Q 



LOXAM [C.L.), 

Profexsor ofOMiniHryin King's College, London. 

CHEMISTRY, INORGANIC AND ORGANIC. New Edition. In one 

very handsome octavo volume, of about 700 pages, with about 300 illustrations. (Pre- 
paring.) 

LO WES (FRANK), D.Sc. London. 

Senior Science-Master at the HighSchool, Keu>castle-?ini1er-Lyme,etc. 

A^S ELEMENTARY TREATISE ON PRACTICAL CHEMISTRY 

AND QUALITATIVE INORGANIC ANALYSIS. Specially adapted for Use in the 
Laboratories of Schools and Colleges and by Beginners. Second American from the 
Third and Revised English Edition. In one very handsome royal 12mo. volume of 
372 pages, with 47 illustrations. Cloth, $2 50. (Just Issued.) 

for itself manv warm friends and supporters. It 
treats the subject well and the tabl"> are very clear 
and valuable. — St. Louis Med. and Surg. Journ., 
Mar. 1881. 



The book is eminently a practical one, and we can 
cordially recommend it as one of the best text-books 
for practical inslruclion in the laboratory. The an- 
alytical reactions and methods are those which ex- 
perience has proved to be the most accurate, and the 
directions for workiug are given so fully as to be 
perfectly intelligible tothe btudeut without extended 
verbal explanation from the instructor. — Boston 
Med. and Surg. Journ., March, 1881. 

A compact manual of qualitative inorganic analy- 
sis, well suited for class use or for the private stu- 
dent. The book has beencarefully revised through- 
out, and some processes have been materially sim- 
phtied. —Boston Journ. of chemistry, March, 1881. 

This is a valuable work for those about to com- 
mence chemistry, the more *o as by its use they are 
simultaneously acquainted with the manipulation 
of chemical analysis, a method which is the most 
valuable to impart a thorough knowledgeof chemis- 
try. It is a verv good little book, and will make 



This work is not only well adapted for use as a 
text-book in medical colleges, but is also one of the 
be>t that a practitioner can have for convenient re- 
ference and instruction in his library. Asa rule, 
such volumes are too technical and abstruse for 
study without some didactic aid, but the volume 
presented is easy of comprehension, and will be of 
greit value to college students and bn*v practition- 
ers.— Am. Mtd. BUWeekly, April 9, 1881. 

The tables particularly demand praise, for they 
are admirably formed, both for convenience of re- 
ference and fulness of information. In short, we 
do not remember to have met with a book which 
could better serve the student as a guide to the sys- 
tematic studv of inorganic chemistry. — Louisville 
Med. News, March 12, 1881. 



fTOFFMA NN [FRED.), A.M., pOWER {FRED. B.), Ph.D., 

-*- Ph.D., and Prof of Anal. Chem. in Phil. Odil. of Pharmacy- 

A MANUAL OF CHEMICAL ANALYSIS, as Applied to the Exami- 
nation of Medicinal Chemicals and their Preparations. Being a Guide for the Determi- 
nation of their Identity and Quality, and for the Detection of Impurities and Adultera- 
tions. For the Use of Pharmacists', Physicians, Druggists and Manufacturing Chemists, 
and Pharmaceutical and Medical Studerts. Third Edition, entirely rewritten and much 
enlarged. In one very handsome octavo volume, fully illustrated. (In Press.) 



H 



ERMANN(L.). 

Professor of Physiology in the Unixersity «f Zurichr, 



EXPERIMENTAL PHARMACOLOGY. A Handbook of Methods 

for Determining the Physiological Actions of Drugs. Translated, with the author's 
permission, and with extensive additions, by Robert Meade Smith, M.D., Demonstrator 
of Physiology in the University of Pennsylvania. (In a jew days ) 



Henry C. Lea's Son & Co.'s Publications— (Phar., Mat. Med., etc.). 1 1 



pARRISH {ED WARD), 

-*- Late Professor of Materia Medica in the Philadelphia College of Pharmacy. 

A TREATISE ON PHARMACY. Designed as a Text-Book for the 

Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and 
Prescriptions. Fourth Edition, thoroughly revised, by Thomas S. Wiegand. In one 
handsome octavo volume of 985 pages, with 280 illustrations ; cloth. $5 50; leather, $6 50; 
half Russia, $7 

the public with all the mature experience of its au- 
thor, and perhaps none the worse for a dash of new 
blood. — Lond. Pharm. Journal, Oct. 17, 1874. 

The work is eminently practical, and has the rare 
merit of being readable and interesting, while it pre- 
serves astrictlyscientificcharacter. The whole work 
reflects the greatest credit on author, editor, and pub- 
lisher.— Med. Press and Circular, Aug. 12, 1874. 



Perhaps one of the most important, if not the 
most important book upon pharmacy which has 
appeared in the English language has emanated 
from the transatlantic press. "Parrish's Phar- 
macy" is a well-known work on this side of the 
water, and the fact shows us that a really useful 
work never becomes merely local in its fame. 
Thanks to the judicious editing of Mr. Wiegand, the 
posthumous edition of "Parrish" has been saved to 



QRIFFITH (R. EGLESFIELD), M.D. 

A UNIVERSAL FORMULARY, .Containing the Methods of Prepar- 
ing and Administering Officinal and other Medicines. The whole adapted to Physicians and 
Pharmaceutists. Third Edition, carefully revised and much enlarged, by John M. Maisch, 
Phar.D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large 



and handsome octavo volume of about 
A more complete formulary than itis in its pres- 
ent form the pharmacist or physician could hardly 
desire. To the first some such work is indispensa- 
ble, and it is hardly les3 essential to the practitionei 
who compounds his own medicines. Much of what 
is contained in the introduction ought to be com- 



U pages. Cloth, $4 50 ; leather, $5 50. 
mitted to memory by every student of medicine. 
As a help to physicians it will be found invaluable, 
and doubtless will make its way into libraries not 
already supplied with a standard work of the kind. 
— The American Practitioner, J uly, 1874. 



CfTILLE {ALFRED), M.D., LL.D. 

*3 Professor of Theory and Practice of Medicine in the University of Pennsylvania. 

THERAPEUTICS AND MATERIA MEDICA ; a Systematic Treatise 

on the Action and Uses of Medicinal Agents, including their Description and History. 
Fourth Edition, revised andenlarged. Intwolargeand handsomeoctavovolumes of about 
2000 pages. Cloth, $10 ; leather, $12; half Russia, raised bands, $13. 



For all who desire a complete work on therapeu- 
tics and materia medica for reference, in cases in- 
volving medico-legal questions, as well as forin- 
formationconcerningremedial agents, Dr. Still6'sis 
"par excellence" the work. Being out of print, by 
the exhaustion of former editions, the author has laid 
the profession under renewed obligations, by the 
:arefnl revision, importantadditions, and timely re- 
issuing a work not exactly supplemented by any 
other in the English language, if in any language. 
The mechanical execution handsomely sustains the 
well-known skill and good taste of the publisher. — 
St. Louis Med. and Surg. Journal, Dec 1S74. 

The rapid exhaustion of three editions and the uni 
vevsal favor with which the work has been received 
by the medical profession, are sufficient proof of it' 



excellence as a repertory of practical and useful in- 
formation for the physician. The edition before us 
fully sustains thjs verdict, as the work has been care- 
fully revised and in some portions rewritten, bring- 
ing it up to the present time. — American Journal 
of Pharmacy, Feb. 1S75. 

We can hardly admit that it has a rival in the 
multitade of its citations and the fulness of its re- 
search into clinical histories, and we must assign it 
a place in the physician's library; not, indeed, as 
fully representing the present state of knowledge in 
pharmacodynamics, but as by far the most complete 
treatise upon the ciinical and practical side of the 
question. — Boston Med. and Surg. Journal. Nov 6, 
1874. 



PARQUHARSON (ROBERT), M.D. , 

•*■ Lecturer on Materia Medico, at St. Mary's Hospital Medical School. 

A GUIDE TO THERAPEUTICS AND MATERIA MEDICA. Third 

American Edition, specially revised by the Author. Enlarged and adapted to the U. S 
Pharmacopoeia. By Frank Woodbury, M.D. In one very handsome 12mo. volume o 
524 pages. Cloth, $2 25. {Just Rearly.} 

From the Editor's Preface to the Third Edition. 
The present volume is an intelligent effort to present, in moderate compass, such well-digested 
facts concerning the physiological and therapeutical action of remedies as are reasonably estab- 
lished up to the present time. By a convenient arrangement the corresponding effects of each 
article in health and disease are presented in parallel columns, not only rendering reference 
easier, but also impressing the facts more strongly upon the mind of the reader. The author 
has thought it advisable to introduce the metric system in addition to the old form of writing 
prescriptions, in deference to the demands of scientific progress and uniformity of observation. 
A ready reference table of Poisons has been placed at the end of the book, and in the text itself 
the tests of the prominent poisons have been inserted. It is hoped that the very careful revision 
and additions that have been made to the work (which have increased its size nearly one-third) 
have proportionally increased its value to the student. 



The general arrangement, the excellent manner 
in which the individual articles are presented, the 
eminently practical character together with the 
positiveness of expression in both the physiological 
and therapeutical indications of special remedies, 
and the fact that it is fully abreast with the most 
recent developments of scientific investigations, all 
tend to make this little volume peculiarly valuable. 
Itis throughout complete in all the necessary de- 
tails, clear and lucid in its explanations, and not 
only a handy little volume but may be regarded as 
authority.— The Southern Practitioner, Dec. 18S2. 



That a third edition of this work should be de- 
manded within five years after the appearance of 
the first, is conclusive proof that the book is a popu- 
lar one. That its popularity is deserved no ore can 
doubt who carefully reads the book. The double- 
column arrangement beautifully shows the rela- 
tions between the physiological and therapeutical 
action of the drugs. As a text-book for students we 
kuow of nothing so concise and clear. As a hasty 
reference book for practitioners it has no superior.— 
Cincinnati Lancet and Clinic, Nov. 25, 1882. 



12 Henry C. Lea's Son <fe Co.'s Publications — (Mat. Med. and Therap.). 
SJTJLLE (ALFRED), M.D., LL.P., and JLfAlSCH (JOHN M.). Phar.D., 

O Prof of Th';ry and Practice of Medicine ■*■"- Pruf. of Mat. Med. and But in Phila. 

and of Olinical Med. in Univ. of Pa. Coll. Pharmacy, Secy. to the American 

Pharmaceutical Association. 

THE NATIONAL DISPENSATORY: Containing the Natural History, 

Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in 
the Pharmacopoeias of the United Ft.ites, Great Britain and Germany, with numer- 
ous references to the French Codex. Second Edition, thorough- revised, with numerous 
Additions. In one Tery handsome octavo volume of 1092 pastes, with 239 illustration.-. 
Extra cloth, $fi 75; leather, raised bands, $7 50; half Russia, raised bands and open 
back, $8 25. (Now Ready.) 

In the recent announcement of the United States Pharmacopoeia of 1880, a list 

d of new materia] inserted, and of the 102 items under the head of New Drugs, 

-.:• Extracts, all are in the National Disprnsatort excepting 6, while of the 

Fluid Extracts quite a large proportion is included. Besides embracing practically 

the whole United States Pharmacopoeia the National Dispensatory contains a long 

list of unofficinal drags and preparations, and also selections from the receut German 

and French Pharmacopoeias. Purchasers will therefore find that the National 1>is- 

Becond edition, is, for all practical purposes, a commentary on the United 

States Pharmacopeia of 1880. 

From the Preface to the Second Edition. 

The opportunity for a revision has enabled the authors to scrutinize the work as a whole, and 
to introduce alterations :ind additions wherever there has seemed to be occasion for improve- 
ment or greater completeness. The principal changes to be noted are the introduction of seve- 
ral drugs under separate headings, and of a large number of drugs, chemicals and pharma- 
ceutical preparations classified as allied drugs and preparations under the heading of more 
important or better known articles; these additions comprise in part nearly the entire German 
Pharmacopoeia and numerous articles from the French Codex. All new investigations which 
came to the authors' notice up to the time of publication have received due consideration. 

The series of illustrations has undergone a corresponding thorough revision. A number have 
been added, and still more have been substituted for such as were deemed less satisfactory. 

While numerous additions have been made to the sections which relate to the physiological 
action of medicines and their use in the treatment of disease, great care has been taken to 
make them as concise as was possible without rendering them incomplete or obscure. The 
doses have been expressed in the terms both of troy weight and of the metrical system, for the 
purpose of making those who employ the Dispensatory familiar with the latter, and paving the 
way for its introduction into general use. 

The Therapeutical Index has been extended by about 2250 new references, making the total 
number in the present edition about 6000. 

This evidence of success, seldom paralleled, i whicb proves that the authors do not intend to let 



lows clearly how well the authors have met 
existing needs of the pharmaceutical and medical 
professions. Gratifying as it must be to thern, they 
have embraced the opportunity offered for a thor- 
ough revision of the whole work, striving to em- 
brace within ir all that might have been omitted 



the grass grow under their feet, but to keep the 
work up to the time. — New Remedies, Nov. 1S79. 

This is a great work by two of the ablest writers on 
materia medica in America The authors have pro- 
duced a work which, for accuracy and comprehensive- 



™ •»*«"«»■» l " a Tftv T ueeu uu " t,eu '" ness, is unsurpassed by any work on the subject. There 
the former edition, aud all that hasnewiy appeared is n0 book in the English language «hich contains so 
of sufficient Importance during the time, of Its col- much valuabU inlormation n the various articles of 
laboratiou, and the short interval elapsed since he : the mat eria medica. The work has cost the authors 
previous publication. After having gone carefully g of ]aborious study but they have succeeded in 

through the volume we must admit that the authors , p roduclng a , iis ,,en<atorv which is not only national, 
have labored faith fully, aud with success, in main- but will be a , asti memoria i of their learning.- 
taming the high character of their work as a com- minburg h Medical Journal, Nov. 1879. 
pendnun meeting the requirements of the day, to ... . . , , ., 

which one can safelv tnru in quest of the latest in- i It is by far more international or universal than 
formation concerning everything worthy of notice in I an y 0,her bo u ok of ll ? e k,nd la our language and 
connection with Pharmacy, Materia Medica, aud : more comprehensive in every sense.-Pocyfc Af«d. 
Therapeutics.— Am. Jour, of Pharmacy, Nov. 1879. i and Surg. J own., Oct. 1879. 

It i» with great pleasure that we announce to our The National Dispensatory is beyond dispute the 
readers the appearance of a second edition of the ! very best authority. It is throughout complete in 
Nitional Dispensatory. The total exhaustion of the all the necessary details, clear aud lucid in itb ex- 
first edition in the short space of six months, is a planations, aud replete with references to the most 
sufficient testimony to the value placed upon the recent writings, where further particulars can be 
work by the profession. The rapid sale of the first obtained, if desired. Its value is greatly enhanced 
edition must have induced both the editors and the , by the extensive indices — a general index of materia 
publisher to make preparations for a new edition \ medica, etc., and also an index of therapeutics No 
immediately after the first had been Issued, for we , practising physician can afford to be without the 
find a large amount of new matter added and a good National Dispensatory.— Canada Med. and Surg. 
deal of the previous text altered and improved, , Journ., Feb. 1880. 



Henry C. Lea's Son & Co.'s Publications — (Mat. Med. & Histology). 13 



TlfAISCH (JOHN M.), Fhar. D., 

Prof, of Materia Mediea and Botany in the Phila. OoTt. of Pharmaey. 

A MANUAL OF ORGANIC MATERIA MEDICA. Being a Guide 

to Materia Mediea of the Vegetable and Animal Kingdoms. For the use of Students, 
Druggists, Pharmacists and Physicinns. In one handsome royal 12mo. volume of 451 
pages, with 194 beautiful illustrations on wood. Cloth, $2 75. (Just Ready.) 



A book evidently written for a purpose, and not 
simply for the purpose of writing a book. It is 
comprehensive, inasmuch as it refers to all, or 
nearly all, that is of essential value in organic 
materia mediea, clear and simple in its style, con- 
cise, since it would be difficult to find in it a super- 
fluous word, and yet sufliciently explicit to satisfy 
the most critical. The text is freely illustrated with 
woodcuts, which cannot fail to be valuable in 
familiarizing students with the physical, micro- 
scopic, and macroscopic appearance of drugs The 
work is preceded by a table of contents, and com- 
pleted with that, without which no book should be 
considered complete, i.e., an index. In fact, the 
little book is just what it pretends to be, and is 
worthy of unqualified commendation. — Chicago 
Medical Journal and Examiner, Aug. 1882. 



tional Dispensatory, is a work for which students 
of pharmacy should be grateful. The subject is one 
in which the beginner needs the guidance of a good 
classification in order to avoid the bewilderment 
which follows the attempt to grasp a wubject having 
so many details. This condition the book fulfils, 
the classification adopted being a simple and prac- 
tical one ; the notice of each drusr is brief and clear, 
non-essentials being omitted. It is fully illustrated 
by some two hundred woodcuts. — Boston Med. and 
Surg. Journ., Jan. 19, 1882. 

Besides being of value to the student, the work 
will be a great aid to the druggist in his purchases, 
enabling him to detect adulterations. The work is 
from a master in his department, and is an evidence 
of the truly scientific study that is now being pur- 
sued in pharmacology. — Physician and Surgeon, 
Feb. 1882. 



The above manual, by a well known authority : 
this department and one of the authors o f the Na- 

(10RNIL (V.), AND JDANVIER (L.), 

^ Prof, in the Faculty of Med. of Paris. -*-*' Prof in the College of France. 

A MANUAL OP PATHOLOGICAL HISTOLOGY. Translated, with 

Notes and Additions, by E. 0. Shakespeare, M.D., Pathologist and Ophthalmic Surgeon 
to Philada. Hospital, Lecturer on Refraction and Operative Ophthalmic Surgery in Univ. 
of Penna., and by J. Henry C. Stmes, M D., Demonstrator of Pathological Histology in 
the Univ. of Pa. In one very handsome octavo volume of 800 pnges, with 360 illus- 
trations. Cloth, $5 50; leather, $6 50; half Russia, $7. (Now Ready.) 



Every student of pathology — and every practi- 
titioner ought to be a student of pathology — should 
have Cornil and Rnnvier amongst his books, and he 
will find it invaluable for reference in working up 
his cases; in fact, a great deal of well-condensed 
matter is collected together here which is not easilv 
found in the same form anywhere else. — Can. Med. 
and Surg. Journal, June, 1880. 

Their book is not a collection of the works of 
others, but has been written in the laboratory be- 
side the microscope. It bears the marks of personal 
knowledge and investigation upon every page, con- 
trolled by and controlling the work of others. In 
short, its translation has made it the best work in 
pathology attainable in our language, one that every 
student certainly ought to have. — Archives of Med- 
icine, April, 1880. 

"We have no hesitation in cordially recommend- 
ing the translation of Cornil and Ranvier's " Patho- 
logical Histology" as the best work of the kind 
in any language, aDd as giving to its readers a 
trustworthy guide in obtaining a broad and solid 
basis for the appreciation of the practical bearings 



of pathological anatomy. — Am. Journ. of Med. 
Sciences, April, 1880. 

This important work, in its American dress, is a 
welcome offering to all students of the subjects 
which it treats. The great mass of material is 
arranged naturally and comprehensively. The 
classification of tumors is clear and full, so far as 
the subject admits of definition, and this one chap- 
ter is worth the price of the book. The illustra- 
tions are copious and well chosen. Without tbe 
slightest hesitation, the translators deserve honest 
thanks for placing this indispensable work in the 
hands of American students. — Phila. Med. Times, 
April 24, 1880. 

This volume we cordially commend to th e profes- 
sion. It will prove a valuable, almost necessary, 
addition to the libraries of students who are to be 
physicians, and to the libraries of students who are 
physicians.— American Practitioner, June, 18S0. 

The best and most complete work ever issued on 
the subject from the pres^ of any country. — London 
Medical Press and Circular. 



CfOHAFER {ED WA RD ALBERT), M.D., 

^ Assistant Professor of Physiology in University College, London. 

A COURSE OF PRACTICAL HISTOLOGY: Being an Introduction to 

the Use of the Microscope. In one handsome royal 12mo. volume of 308 pages, with 
numerous illustrations. Cloth, $2 00. 

fIREEN ( T. HENR Y) , MD~„ 

^-* Lecturer on Pathology and Morbid. Anatomy at Charing-Cross Hospital Medico I School, etc. 

PATHOLOGY AND MORBID ANATOMY. Fifth American, from 

the Sixth Enlarged and Revised English Edition. In one very handsome octavo volume 
of about 350 pages, with about 150 fine engravings. (Preparing.) 
A few notices of the previous edition are appended. 

All the good 'Mugs that have been said and writ- 



No late discovery or investigation has been over- 
looked, and the illustrations are the best that ever 
accompanied any book on the subject. In few de- 
partments of medicine has so much progress been 
made of late as in that of pathology, supported as it 
is by the promising sciences of biology and physio- 
logical chemistry, and these lie at the basis of sci- 
entific treatment. It will repay most practitioners 
to peruse this book at least two or three times. — 
Chicago Med. Journ. and Examiner, Feb., 18S2. 

If the practitioner has an ambition to excol or a 
desire to advance in truth the science of medicine, 
he should be familiar with pathological and morbid 
anatomy as described in the book now on our table. 
— Va. Med. Monthly, July, 1881. 



t=>n of previous editions apply with added forfe to 
this, and we know not bow to recommend the book 
too highly to all students and to th.se practitioners 
who have not a recent edition, and who care to 
know the why and wherefore of those processes 
which fall under their daily observation.— Caw. 
Journ. of Med. Science, Aug. 18S1. 

We have long considered this the best guide yet 
presented to tbe student for the identification of va- 
rious morbid tissues. We have found it more satis- 
factory than any other. The present edition has 
b^en thoroughly revised, and much new matier 
has been added. To the physician, as a guide in 
diagnosis, we recommend this volume. — Physician 
and Surgeon, May, 1881. 



Henry C. Lea's Son «fc Co.'s Publications — (Practice, etc.). 



JDRISTO WE {JOHN STER), M.D . FRCP., 

J~s PTiyttetan and Joint Lteturer on Medicine at St. Thomas' Hospital. 

A TREATISE OX THE PRACTICE OF MEDICINE. Second 

American Edition, revised by the Author. Edited, with Additions, by James H. IIutch- 
rtraoif, M.D., Physician tothe Pennn. Hospital. In one handsome octavo volume of 
1085 pages, with illustrations. Cloth, $5 00; leather, $6 00; half Russia, raised 
bands, $6 50. (Lately Issued.) 
The second edition of this excellent work, like the and the book is a fair reflex of all that is certainty 



flrr-t, has received the benefit of Dr. Hutchinson's 
annotations, by which the phages of disease which 
ulirtr to this country are indicated, and thus 
a treatise which was intended for British practi- 
- and students is made more practically tin, fill 
on this side of the water. We see no reason to 
modify the high opinion previous v expressed with 

to Dr. Bristol* work except by adding " M ' S e, : u lo'ess toAmerica~n' readers" 
our appreciation of the careful labors of the author H Journ., March, 1S&0. 

ia following the latest growth of medical science. " ,. ,, . . , , , , 

-Boston Medical and Surgical Journal, February, . ^e regardit as an excellent work for students and 
jggQ " for practitioners. It is clearly written, the author s 

. , „ . m . .... ... -tvle is attractive, and it is especially to be com- 

\\ hat we said of the first edition, we can with mftQ(}pd forit9 excellent exposition of the pathology 
i ncreased emph«s,s, repeat concerning ibis: •• Ever j and ollllical phenomena of disease.— St. Lojtis Clin. 
pagetscharscterized by the ntterance-o! a thought- R ecor d F eD . 1380 
ful man. What has been said, has been well said, 



known on the subjects considered." — Ohio Med. 
Recorder, Jan. 7, 1SS0. 

The reader will find every conceivable subject 
counected with the practice of medicine ably pre- 
sented, in a style at once clear, interesting and con- 
cise. The additions mide by Dr. Hutchinson are 
appropriate and practical, and greatly add to its 
Buffalo Med. and 



PEN WICK ( SA M UEL). M.D., 

-*- Assistant Phusician to (he London Hospital. 

THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the 

Third Revised and Enlarged English Edition. In one very handsome royal 12mo. 
volume of 328 pages, with 87 illustrations on wood. Cloth, $2 25. 

POTHERGILL (J. MILNE R), M.D. Edin., M.R.C.P. Land, 

A- Asst.Phys.tothe West Land Hosp. : Asst. Phyx.to the City of Loivl . Hasp., etc. 

THE PRACTITIONER'S HANDBOOK OF TREATMENT; Or, The 

Principles of Therapeutics. Second Edition, revised and enlarged. In one very hand- 
some octavo volume of about fi50 pages. Cloth, $4 00; very handsome half Russia, 
raised bands, $5 50. [Jutt Issued.) 
A book which can give correctly and interestingly I ties of a well- written novel. No physician can 
as well as scientifically, the method of pre?ciibiug ■ well afford to be without this valuable work, for its 
and the rationale of the bes' therapeutics in the | orizioality makes it fill a niche in medical lifera- 



treatraent of disease, is manifestly just the w 
which each physician desires. It is not extrava- 
gant eulogy to say that the physician will find in 
ttjis K-ork of Fi thergill the guide which he seeks for 
bis therapeutics ; tor not only is the treatment 
which he seeks already indicated herein, but the 
rationale of the treatment is as clearly explained. 
—Gaillard's M-d. Journ., Sept. 16S0. 

The author merits the thanks of every well-edu- 
cated physician for his efforts toward rationalizing 
the treatment of diseases upon the scientific basis 
..f physiology. Every chapter, every line, has the 
impress of a master hand, and while the work is 
thoroughly scientific in -very particular, 



ture hitl 



vacant. — Ifashville Journ. of Med. 



The juuior members of the prcfession will find in 
it a wuik that should not only be read, but care- 
fully studied. It will assist them in the proper 
selection and combination of therapeutical ageirs 
best adapted to each case and condition, and enable 
them to prescribe intelligently and successfully. 
To do full justice to a work of this scope and char- 
acter will be impossible in a review of this kind. 
Theb ok itself must be read to be fully appreciated 
— St. Louis Courier of Medicine, Nov. 1SS0. 

Both in matter and manner the book is most thor- 
Ohio Med. Recorder, Oct. 18S0. 



it present* oug hi y excellent 
thoughtful reader all the charms and beau- | 

fJABERSHON (S. 0.) M.D. 

A J. Senior Physician to and late Lecturer on the Principles and Practice of Medicine at Guy's 

Hospital, ete. 

ON THE DISEASES OF THE ABDOMEN, COMPRISING THOSE 

of the Stomach, and other parts of the Alimentary Cnnal, (Esophagus, Caecum, Intes- 
tines and Peritoneum. Second American, from the Third Enlarged and Revised Eng- 
lish Edition. With illustrations. In one handsome octavo volume of 554 pages, with 
illustrations. Cloth, $3 50. (Lately Issued.) 



This valuable treatise on diseases of the stomach 
aod abdomen has been on t of prinl for several years, 
and is therefore not so well known to the profession 
a- it deserves to be. It will be found a cyclopedia 
of information, systematically arranged, on all dis- 
eases of the alimentary tract, from the month to the 
rectum A fair proportion of each chapter is devoted 
to symptoms, pathology and therapeutics. The 
present edition is fuller than former ones in many 
particulars, and has been thoroughly revised and 



amended by the author. Several new chapters ha ve 
been added, bringing the work fully up to the times, 
and making it a volume of interest to the practi- 
tioner in every field of medicine and sursrery. Per- 
verted nutrition is in some form associated with all 
diseases we have to combat, and we need all the 
light that can he obtained on a subject so broad and 
general. Dr Habershon's work is one that every 
practitioner should read and study for himself. — 
.V. Y Med. Journ , April, 1S79. 



GbUGE'S ATLAS o F PATHOLOGICAL HISTOLOGY. 
Translated, with Notes and Additions, by JosEm 
Leidt, M. D. In one volume, very largeimperial 
quarto, with 320 copper-plate figures, plain and 
colored. Cloth, $4 00. 

HOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol. 8vo , pp. 500. Cloth, $3 50. 

BULOW'S MANUAL OF THE PRACTICE OF 
MUHCINE. With Additions by D. F. Cosdie, 
M.D. lvol.8vo. pp.600. Cloth, $2 50. 



LA ROCHE ON YELLOW FEVER. considered in its 
Historical, Pathological, Etiological and Thera- 
peutical Relations. In two large and handsome 
octavo volnmesofnearly 1500 pp. Cloth, $7 00. 

LA ROCHE ON PNEUMONIA. 1 vol. 8ro. of 490 
paares. Cloth, $3 00. 

PAYY'S TREATISE ON THE FUNCTION OF DI- 
GESTION: its Disorders and their Treatment. 
From the Second London Edition. In one hand- 
some volume, small octavo. Cloth, $2 00. 



Henry C. Lea's Son & Co.'s Publications — (Practice of Medicine). 15 



TLINT {A USTIN), M.D., 

Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. T. 

k TREATISE ON THE PRINCIPLES AND PRACTICE OF 

MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fifth 
Edition, entirely rewritten and much improved. In one large and closely printed octavo 
volume of 1150 pages. Cloth, $5 50 j leather, $6 50; very handsome half Russia, raised 
bands, $7. (Just Issued.) 

years before it yields the place to others. — Nash- 
ville Jonrn. of Med. and Surg., Feb. 1881. 

"Flint's Practice" is recognized to be a standard 
treatise of high rank upon the principles and the 
practice of medicine wherever the English language 
is read. The opinions everywhere reveal the man 
of extensive experience, dilieent study, calm judg- 
ment, and unbiassed criticism. The work thnuld 
be in the hands of every practitioner. — New Turk 
Med. Record, Feb. 26, 1881. 



This work has been so long and favorably known, 
and has obtained so high a position amongst mod- 
ern treatises on medicine, that it is hardly neces- 
sary to do more than announce the publication of 
this fifth edition. All who peruse it must be struck 
by the extensive research which has been under- 
taken in the revision of this edition, combined with 
much original thought. There is hardly a subject 
which does not receive fresh illustration and discus- 
sion, opening up new lines of inquiry which ha 1 not 
been thought of when the previous edition appeared. 
We cannot conclude this notice without expressing 
our admiration of this volume, which is certainly 
one of the standard text-books on medicine, and we 
may safely affirm that, taken altogether, it exhibits 
a fuller and wider acquaintance with recent patho- 
logical inquiry thad any similar work with which 
we are acquainted, whilst at the same time it sho 
author to be posses; 



The style and character of this work are too well 
known to the profession to require an introduction. 
For a number of years this volume has occupied a 
leading position as a text-book in the majority of 
medical schools, and the high position accorded to 
it in the past is a guarantee of a hearty welcome in 
this new edition. The book may be said to represent 
the rare faculties of tne present state of the science of medicine as now 
clear exposition," thoughtful discrimination, and! understood and taught. It is a safe guide to students 
sound judgment.— London Lancet, July 23, 1681. i aQd practitioners of medicine.— JKar^aad Medical 
J * , , . , ; Journal, March 1, 18S1. 

Practically, this edition is a new work; for so; . - ■ . . 

many additions and changes have been made that \ Tu « a ^ h °r has. in this edition revised and re- 
cue well acquainted with previous editions would I written a great part and made it accord with the 
hardly recognize this as an old friend. The size of ; m . ore . advanced ideas which have been developed 
the volume is somewhat, increased. An entire new j 
section and several new chapters have r - __ 



It is universally conceded that no text book upon 
this subject was ever published in this country 
that can at all compare with it. It has long been 
at the very head of American text-book literature, 
and there can be no doubt but that it will be many 



meed ideas 
lin the past few years. He is the more fitted to 
o, as he is actively engaged in his profession, 
and can make deductions, not from the work of 
others, but from his own labors. It is a treatise 
which every American physician should ha^e upon 
his table, and which he should consult on occasions 
when his leisure permits him to do so. — St. Louis 
Med. and Surg. Journal, March, 1881. 



THE SAME AUTHOR. 

CLINICAL MEDICINE; a Systematic Treatise on the Diagnosis 

and Treatment of Diseases. Designed for Students and Practitioners of Medicine. In 
one large and handsome octavo volume of 799 pages. Cloth, $4 50 ; leather, $5 50; 
half Russia, $6. (Lately Issued.) 

in this country as that of the author of two works 
of great merit on special subjects, and of numerous 
papers, exhibiting much originality and extensive 



The eminent teacher who has written the volume 
cinder consideration has recognized the needs of 
the American profession, and the result is all that 
we conld wish. The style in which it is written is 
peculiarly the author's ; it is clear and forcible, and 
marked by those cbaraeteristies which have ren- 
dered him one of the best writers and teachers this 
country has ever produced. We have not space for 
so full a consideration of this remarkable work as 
we would desire.— Si. Louis Clin. Record, Ott. 1879. 

It is here that the skill and learning of the great 
clinician are displayed He has given us a store- 
house of medical knowledge, excellent for the stu- 
dent, convenient for the practitioner, the result of a 
long life of the most faithful clinical work, collect- 
ed by an energy as vigilant and systematic as un- 
tiring, and weighed by a judgment no less clear 
than his observation is close.— Archives of Medi- 
cine, Dec. 1879 

To give an adequate and useful eou^pectus of the 
extensive field of modern clinical medicine is a task 
of no ordinary difficulty; bnt to accomplish this 
consistently with brevity and clearness, the different 
subjects and their several parts receiving the atten- 
tion which relatively to their importance, medical 
opinion claims for them, is still more diffi cult. This 
task we feel bound to say has been executed with 
more than partial success by Dr. Flint, whose name 
is already familiar to students of advanced medicine 



research. — The Dublin Journal, Dec. 1879. 

There is every reason to believe that this book 
will be well received. The active practitioner is 
frequently in need of some work that will enable 
him to obtain information in the diagnosis and 
treatment of cases with comparatively little labor. 
Or. Flint has the faculty of expressing himself 
clearly, and at the same time so concisely as to 
enable the searcher to traverse the entire ground 
of his search, and at the same time obtain all that 
is essential, without plodding through an intermi- 
nable space.— N. Y. Med. Jour., Nov. 1879 

The great object is to place before the reader the 
latest observations and experience in diagnosis aud 
treatment. Such a work is especially valuable to 
students. It is complete in its special design, and 
yet so condensed, that he can by its aid, keep up 
with the lectures on practice without neglecting 
other branches. It will not escape the notice of the 
practitioner that such a work is most valuable in 
calling points in diagnosis and treatment in the iu- 
tervals between the daily rounds of visits, since he 
can in a few minutes refresh his memory, or learn 
the litest advance in the treatment of diseases which 
demand his instant attention. — Cincinnati Lancet 
and Clinic, Oct. 25, 1879. 



jg F THE SAME AUTHOR. 

ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED 

TOPICS. In one very handsome royal 12mo. volume. Cloth, $1 38. 



DAVIS' CLINICAL LECTURES ON VARIOUS IM- 
PORTANT DISEASES; being a collection of the 
Clinical Lectures delivered in the Medical Wards 
of Mercy Hospital, Chicago. Edited by Frank H. 
Davis, M.D. Second Edition, enlarged. In one 
handsome royal i2oao. volume. Cloth, $1 75. 

CHAMBERS' MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one handsome 
octavo volume. Cloth, $2 75. 



STURGES' INTRODUCTION TO THE STUDY OF 
CLINICAL MEDICINE. Beinga Guide to the In- 
vestigation of Disease. In one handsome 12m o. 
volume. Cloth, $125. 

TODD'S CLINICAL LECTURES ON CERTAIN 
ACUTE DISEASES. In one octavo volume, of 320 
pages. Cloth, $2 50. 



16 Henry C. Lea's Son & Co.'s Publications — {Practice of Medicine). 
UICHARDSOX {BEXJ. W.), M.A.. M.D., LL.D., F.R.S., F.S.A., 

-*-«' Fellow of the R >yal College of Physicians, London. 

PREVENTIVE MEDICINE. In one octavo volume of about 500 pages. 

(Preparing.) 

fJA R TSHORNE { EENR Y), M.D., 

*-*• Late Professor of Hygiene, in the University of Pennsylvania 

ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- 

CINE. A handy book for Students and Practitioners Fifth Edition, thoroughly re- 
vised and rewritten. In one handsome royal 12mo. volume, of 669 pages, with 144 illus- 
trations. Cloth, $2.75 ; half bound, $3.00. (Just Ready ) 
The very great success which has exhausted four large editious of this work shows that the 
author has succeeded in supplying a want felt by a large portion of the profession. It has also 
enabled him in successive revisions to perfeet the details of his plan, and to render the work 
still more worthy of the favor with which it has been received. In the present edition several 
hundred brief additions have been made, a number of new subjects have been written upon, 
especially in connection with the Pathology of the Nervous System, the illustrations have been 
considerably increased, and a large number of new and carefully selected formulae for the admi- 
nistration of medicines have been introduced. An account is given, also, in this edition for the 
first time, of the method of prescribing according to the metrical system, and a section is added 
upon Eyesight, its Examination and Correction. In presenting this edition, therefore, the pub- 
lishers feel that it is in every way worthy a continuance of the favor hitherto accorded this work. 

students and practitioners. So thoroughly has he 
digested his materials, and so attractively has he 
airauged thf m, thut it is a real pleasure to read his 
work. We can cordially commerd it to the favor- 
able Attention of snr h as may desire the aid of its 
pages. That it will be even more helpful in its 
present form than it was in former editions we fully 
believe.— Detroit Lancet, Dec 1SS1. 

The style is condensed and terse, yet simple and 
perspicuous. The author has skilfully picked out 
the kernel from the nut andthrown aside the shells. 
To the everyday practitioner it is a ready help, and 
a thorough study of the subject, will be greatly 
facilitate! by a previous perusal of the essentials. 
The present edition .is a great improvement on its 
predecessors— in fact almost a new book. — Pacific 
Med. and Surg Journal, Jan. 1SS2. 



The author of this book seems to h<i 
pains to bring it up to the modern standpoint, for us 
we turn over its pages we find many subjects intro- 
duced which have only lately been brought before 
the profession. Certainly amongst books of its class 
it deserves and has obtained a good position. On the 
whole it is a careful and conscientious piece of work, 
and may be commended. — Lancet, June 24, 1892. 

As to the popularity of the fifth edition of a med- 
ical work, nothing need be said. Concerning the 
one before us, we need only to say that the author 
has exercised the same good judgment as was ap- 
parent in former editions, and that all recent addi- 
tions to this field hi,ve been l.-iid under contribu- 
tion to fill its pages. As a brief compend of the 
essentials of practical medicine, we have never 
se~n the superior to this work Used ia a proper 
manner it will be of great service to both medical 



WOODBURY {FRANK), M.D.. 

"' Physician to the German Hospital, Philadelphia; late Chief Assistant to the Medical Clinic 

in Jefferson College Hospital, etc. 

A HANDBOOK OF THE PRINCIPLES AND PRACTICE OF 

Medicine ; for the use of Students and Practitioners. In one royal 12mo. volume, with 
illustrations. (Preparing.) 

JPINLAYSON {JAMES), M~Jh, 

L Physician ar, d Lecturer on CI inical Medicine i?i the Glasgow Western Infirmary, etc. 

CLINICAL DIAGNOSIS; A Handbook for Students and Prac- 
titioners of Medicine. In one handsome 12mo. volume, of 546 pages, with 85 illustra- 
tions. Cloth, $2 63. (Lateiy Issned.) 



The book is an excellent one, clear, concis 



ve- five from preface to the final page, and ought to be 



nient, practical. It is replete with the very know- given a place on every office table, because it contai 



ledge the student needs when he quits the lectu 
room and the laboratory for the ward and sick-room, 
and does not lack in information that wil 1 meet 'he 
"•ant* of experienced and older men.— Phil a. Med. 
Times, Jan. 4, 1879. 
This is one of the really useful books. It is attrac- 



ns 
i a condensed form all that is valuable in semeiology 
and diagnostics to be found in bulkier volumes, and 
beca use in its arrangement and complete index, it is 
unusually convenient for quick reference in any 
emergency that may come upon the busy practitioner. 
—Jf. 0. Med. Juurn., Jan. 1S79. 



W: 



A TSON {THOMAS), M.D. 

LECTURES ON THE PRINCIPLES AND PRACTICE OF 

PHYSIC. Delivered at King's College, London. A New American, from the Fifth 
English Edition, revised and enlarged. Edited, with additions, and 190 illustrations, by 
Henry Hartshorne, A.M., M.D., late Professor of Hygiene in the University of Penn- 
sylvania. In two large and handsome octavo volumes. Cloth, $9 00 ; leather, $11 00. 



WILLIAMS ON PULMONARY CONSUMPTION: its 
Nature, Varieties and Treatment. With an Ana- 
lysis of One Thousand Cases to exemplify its 
duration. In one octavo volume of about 35u 
paces. Cloth, $2 50. 

SLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an account ofthe History ofits Pre- 
valence in various Countries. Secondand Revised 
Elition. In one royal 12mo. volume. Cloth, 
|j 25. 



WALSHE ON THE DISEASESOF THE HEART AND 
GREAT VESSELS. Third American Edition. In 
1 vol. Svo., 420 pp. Cloth, $3 00. 

SMITH ON CONSUMPTION ; ITS EARLY AND RE- 
MEDIABLE STAGES. 1vol. Svo., pp.264. $2 25. 

FDLLER ON DISEASES OF THE LUNGS AND AIR- 
PASSAGES. Their Pathology, Physical. Diagnosis, 
Symptoms and Treatment. From the Second and 
Revised English Edition. In onehandsorne octavo 
volume of about 500 pages. Cloth, $3 50. 



Henry C. Lea's Son & Co.'s Publications — (Practice of Medicine). 17 
"REYNOLDS {J. RUSSELL), M.D., 

-*~ v Prof, of the Principles and Practice of Medicine in Univ. College, London. 

A SYSTEM OF MKDICINE. with Not^s and Addition? ry Henry Harts- 
horne, A.M., M.D., late Professor of Hygiene in the University of Penna. In three large 
and handsome octavo volumes, containing 3056 closely printed double-columned pages, 
with 317 illustrations. Price per vol., cloth, $5.00 ; sheep, $6.00 : very handsome half 
Russia, raised bands, $6.50. Per set, cloth, $15; sheep, $18; half Russia, $19.50. 
[Sold only by subscription.) 
Volume I. {now ready) contains General Diseases and "Diseases of the Nervous System. 
Volume II. {now ready) contains Diseases op Respiratory and Circulatory Svstems. 
Volume III. {now ready) contains Diseases op the Digestive and Blood-Glandular 
Systems, op the Urinary Organs, op the Female Reproductive System, and op the 
Cutaneous System. 

Reynolds' System op Medicine, recently completed, has acquired, since the first appearance 
of the first volume, the well-deserved reputation of being the wprk in which modern British 
medicine is presented in its fullest and most practical form. This could scarce be otherwise in 
view of the fact that it is the result of the collaboration of the leading minds of the profession, 
each subject being treated by some gentleman who is regarded as its highest authority — as for 
instance, Diseases of the Bladder by Sir Henry Thompson, Malpositions of the Uterus by 
Graily Hewitt, Insanity by Henry Maudsley, Consumption by J. Hughes Bennet, Dis- 
eases of the Spine by Charles Bland Radcliffe, Pericarditis by Francis Sibson. Alcoholism 
by Francis E. Anstie, Renal Affections by William Roberts, Asthma by Hyde Salter, 
Cerebral Affections by H Charlton Bastian, Gout and Rheumatism by Alfred Baring Gar- 
rod, Constitutional Syphilis by Jonathan Hutchinson, Diseases of the Stomach by Wilson 
Fox, Diseases of the Skin by Balmanno Squire, Affections of the Larynx by Morell Mac- 
kenzie, Diseases of the Rectum by Blizard Curling, Diabetes by Lauder Brunton, Intes- 
tinal Diseases by John Syer Bristowe, Catalepsy and Somnambulism by Thomas King Cham- 
bers, Apoplexy by J. Hughlings Jackson, Angina Pectoris by Professor Gairdner, Emphy- 
sema of the Lungs by Sir William Jenner, etc etc. All the leading schools in Great Britain 
have contributed their best men in generous rivalry, to build up this monument of medical sci- 
ence. St. Bartholomew's, Guy's, St. Thomas', University College, St. Mary's, in London, while 
the Edinburgh, Glasgow and Manchester schools are equally well represented, the Army Medical 
School at Netley, the military and naval services, and the public health boards. That a work 
conceived in such a spirit:, and carried out under such auspices should prove an indispensable 
treasury of facts and experience, suited to the daily wants of the practitioner, was inevitable, and 
the success which it has enjoyed in England, and the reputation which it has acquired on this 
side of the Atlantic, have sealed it with the approbation of the two pre-eminently practical nations. 

Its large size and high price having kept it beyond the reach of many practitioners in this 
country who desire to possess it, a demand has arisen for an edition at a price which shall ren- 
der it accessible to all. To meet this demand the present edition has been undertaken. The 
five volumes and five thousard pages of the original have, by the use of a smaller type and double 
columns, been compressed into three volumes of over three thousand pages, clearly and hand- 
somely printed, and offered at a price which renders it one of the cheapest works ever presented 
to the American profession. 

But not only is the American edition more convenient and lower priced than the English; 
it is also better and more complete. Some years having elapsed since the appearance of a 
portion of the work,' additions are required to bring up the subjects to the existing condition 
of science. Some diseases, also, which are comparatively unimportant in England, require more 
elaborate treatment to adapt the articles devoted to them to the wants of the American physi- 
cian ; and there are points on which the received practice in this country differs from that 
adopted abroad. The supplying of these deficiencies has been undertaken by Henry Harts- 
horne, M.D.,late Professor of Hygiene in the University of Pennsylvania, who has endeavored 
to render the work fully up to the day, and as useful to the American physician as it has proved 
to be to his English brethren. The number of illustrations has also been largely increased, and 
no effort spared to render the typographical execution unexceptionable in every respect. 



Really too much praise can scarcely be given to 
this noble book. It is a cyclopaedia of medicine 
written by some of the best men of Europe. It is 
fall of useful information such as one finds frequent 
need of in one's daily work As a book of reference 
it is invaluable. It is up with the times. It is clear 
and concentrated in style, and its form is worthy 
of its famous publisher. — Louisville Med. News, 
Jan. 31, 1880. 

" Reynolds' System of Medicine" is justly con- 
sidered the most popular work on the principles and 
practice of medicine in the English language. The 
contributors to this work are gentlemen of well- 
known reputation on both sides of the Atlantic. 
Each gentleman has striven to make his part of the 
work as practical as possible, and the information 
contained is such as is needed by the busy practi- 
tioner.— St. Louis Med. and Surg. Journ., Jan. '80. 

Dr. Hartshorne has made ample additions and 
revisions, all of which give increased value to the 
volume, and render it more useful to the Ameri- 
can practitioner. There is no volume in English 
medical literature more valuable, and every pur- 
chaser will, on becoming familiar with it, congrat- 
ulate himself on the possession of this vast store- 
house of information, in regard to so many of the 



subjects with which he should be familiar. — Gail- 
lard's Med. Journ., Feb. 1880. 

There is no medical work which we have in times 
past more frequently and fully consulted when per- 
plexed by doubts as to treatment, or by having un- 
usual or apparently inexplicable symptoms pre- 
sented to us than "Reynolds' System of Medicine." 
Among its contributors are gentlemen who are as 
well known by reputation upon this side of the 
Atlantic as in Great Britain, and whose right to 
speak with authority upon the subjects about 
which they have written, is recognized the world 
over. They have evidently striven to make their 
essays as practical as possible, and while these are 
sufficiently full to entitle them to the name of 
monographs, they are not loaded down with such 
an amount of detail as to render them wearisome 
to the general reader. In a word, they contain just 
that kind of information which the busy practitioner 
frequently finds himself in need of. In order that 
any deficiencies may he supplied, the publishers 
have committed the preparation of the book for the 
press to Dr. Henry Hartshorne, whose judicious 
notesdistributed throughout the volume afford abun- 
dant evidence of the thoroughness of the revision to 
which he hassubiected it. — American Jour nal of the 
Medical Sciences, Jan. I860. 



18 Henry C. Lea's Son & Co.'s Publications — (Nerv. Dis , &c). 
RARTHOLOW (ROBERTS), A.M., M.D..LL.D., 

■*-* Prof, nf Materia Mt&tca and General Therapeutics in the Jefferson Med. Coll. of Phil a., etc. 

A PRACTICAL TREATISE OX ELECTRICITY IN ITS APPLE 

CATION TO MEDICINE. Second Edition. In one very handsome octavo volume of 

296 pages, with 109 illustrations. Cloth, $2 50. (Just Ready.) 
From tiie Preface to the Second Edition. 
In the present edition I have made many additions and improvements to render the work 
more useful to those for whom it is intended. At the same time, in response to what seems to 
me an increasing desire for scientific treatment, I have developed more fully the modern methods 
of ascertaining and expressing current strength, tension, resistances, etc. I have also entered 
more fully into the polar method, and into the action and uses of the magnet. Notwithstand- 
ing an increase in the number of lines to the page, and the condensation of the matter new and 
old, the work has been enlarged by the addition of thirty pages. Thus improved, I may be 
permitted to hope that the new edition will continue to enjoy the favor so largely bestowed on 
the first. 

The second edition of this work following so soon plete with numerous illustrations of instrument-, 
upon the first, would in itself appear to be a suffl- appliances, etc., is printed on fine paper, and band- 

innouncement ; nevertheless, the text has soinely bonnd incloth — Med. Record, Nov. IS, I>v2. 



been so considerably revi-ed and condensed, and 
BO much enlarged by the additiou of new matter. 



It is fortunately not such an interminable 
tUe a- most electro-therapeutists like to write. 



that we cannot tail to recognize a vast improvement Ia not burdened with a needlessly learned terminol- 
upon the lo, mer work. The author has prepared aU( , l9 wr ,„ eQ ,„„, fronj { { , nt of view of 

hie work for -Indents and practitioners; for hose ^'physician than the socialist. The second edi- 

who have never acquainted themselves with the tion has been considerably increased over the fir.-t, 

A I' or ,''r lng d ' J >ne "% C u Dd lhat «f'«' a »>»« and has been brought up to the most recent adl 

heir know edge needs refreshing. We think he vance8 of the gcienc | It ' can in be Te . 

has accomplished his object The book ,s not too commellded t<) tho8e who wigh to / ead a lacid 

voluminous but ,s thoroughly practical, simple, manageable monograph on this form of therapeul 

complete and comprehensible. It is, mor eover, re- tics.JW and Surg. Reporter, Nov. 4, 1682. 

MITCHELL (S. WEIR), M.D., 

- L '- L Phys. to Orthopaedic Hospital and the Infirmary for Dis. of the Nrvous System, Phila., etc etc. 

LECTURES OX DISEASES OE THE NERVOUS SYSTEM, 

ESPECIALLY IN WOMEN. Second Edition. In one very handsome 12mo. volume 

of about 250 pages. (Preparing.) 
The life-long devotion of the author to the subjects discussed in this volume has rendered it 
eminently desirable that the results of his labors should be embodied for the benefit of those 
who may experience the difficulties connected with the treatment of this class of disease. 
Many of these lectures are fresh studies of hysterical affections; others treat of the modifica 
tions his views have undergone in regard to certain forms of treatment, while, throughout the 
whole work, he has been careful to keep in view the practical lessons of his cases. 
A few notices of the previous edition are appended : — 

It is a record of a number of very remarkable i The book throughout is not only intensely enter- 
cases, with acute analyses and discussions, clinical, l taiuiug, but it contains a large amount of rare aud 
physiological and therapeutical It is a book to J valuable information. Dr. Slitchell has recorded 
which the physician meeting with a new hysterical [ not only the results of his most careful observation, 
experience, or in doubt whether his new experience i but has added to the knowledge of the subjects treat- 
is hysterical, may well turn with a well-grounded : ed by his original investigation aud practical study, 
hope of fiuding a parallelism ; it will be a new ex- i The book is one we can commend to all of our read- 
perience, indeed, if no similar one is here recorded ers. — Maryland Med. Journal, May 1, 1881. 

— Phila. Med. Times, June 4, lfrSl. J 

fjAMlLTOS (ALLAN McLANE), M.D., 

Attending Physician at 'the Hospital for Epileptics and Paralytics, Blackwell's Island, N.Y., 
and at the Out- Patient V Department of the. New York Hospital. 

NERVOUSDISEASES;THEIR DESCRIPTION AND TREATMENT. 

Second Edition, thoroughly revised and rewritten. In one handsome octavo volume of 

598 pages, with 72 illustrations. Cloth, $4. (Just Ready.) 

We are glad to welcome a secoud edition of 80 The author's aim is towritea treatise on Nervons 

useful a work as this, in which Dr. Hamilton has ] Diseases which is both concise and practical, while 

succeeded in condensing into convenient limits the it is, at the same time, sufficiently comprehensive. 

mosl important of the recent developments in regard We have pleasure in bearing testimony to the fact 

to diseases of the nervous system. Of recent years that his efforts have been crowned with success. 

nervous pathology has attained to such importance The various diseases have been well described, the 

as to necessitate very careful description in special directions as to how to arrive at a correct diagnosis 

works, and among these this volume must take a are very clear, and the hiutR in treatment are plain, 

high place. This volume is on the whole excellent, practical and sound. Snch a book should be con- 

and is devoid of that spirit of plagiarism which we ; sidered a necessity in erery medical library, as the 

have unfortunately seen too much of in certain recent ailments described are among the most common 

English works on nervous disease. — Edinburgh Med. that come underobservation in the evevy-day w >rk 

Journal, May, 1882. : of the general physician. To him, therefore, we 

__ „ . .... ,,, . , . , j recommend it with pleasure; in fact, we may go 

When the first edition of this good book appeared fnrtll( , r aud „ ay , hat all thing8 considered, It is for 

— gave it our emphatic endorsement, and the pre- his p urp08e tue best w0 ,. k f the kind now avail- 



sent edition enhances our appreciation of the book 
and its author, as a safe guide to students of clin 



■Can. Journ Med. Sciences, April, 1S82. 



...1 neurology. One of the best and most critical of This work is well adapted to the wants of tbe 

English neurological journals, Brain, has charac- general practitioner, for whom it seems to have 

terized this book as the best of its kind in any Ian- h <">° especially written. It is a thoroughly prac- 

guage, which is a handsome endorsement from an t,cal book - the carerul study of which will render 

exalted source. The improvements in the new edi- the diagnosis of nervous affections the more easy 



nd their treatment more successful. The book is 
chase"evenhy those whYpowesYthe old.— Alimtet T . ft .'"y nsefnl a " a "-e^ence work to the busy pra*- 

titioner, to whom we can commend it. — Med. mid 



tion, and the additions to it, will justify its pur- 
base even by those who pass* 
■ui Neurologist, April, 1S52. 



Surg. Reporter, Jan. 21, 



CLINICAL OBSERVATIONS ON FUNCTIONAL I If. D. Second American Edition. In one handsome 
NERVOUS DISORDERS . By C. Ha.vdfield Jones, | octavo to I urn e of 348 pages. Cloth,$3 2o. 



Henry C. Lea's Son & Co.'s Publications — (Bis. of the Skin, So.). 19 



MORRIS (MALCOLM), M.D., 

*■'-*- Joint Lecturer on Dermatology, St. Mary's Hospital Med. School. 

SKIN DISEASES, Including their Definitions, Symptoms. Diagnosis, 

Prognosis, Morbid Anatomy and Treatment. A Manual for Students and Practitioners. 
In one 12mo. volume of over 300 pages, with illustrations. Cloth, $1 75. (Just. Issued.) 
To physicians who would like to know something 



(.bout skin diseases, so that when a patient presen 
himself for relief they can make a correct diagnosis 
fr,nd prescribe a rational treatment, we unhesitatingly 
recommend this little book of Dr. Morris. The affec- 
tions of the skin are described in a terse, lucid man- 
ner, and their several characteristics so plainly set 
forth that diagnosis will be easy. The treatment 
in each case is such as the experience of the most 
eminent dermatologists advises. — Cincinnati Medi- 
cal News, April, 1880. 

This is emphatically a learner's book ; for we can 
safely say, so far as our judgment goes, that in the 



whole range of medical literature of a like sci pet 
there is no book which for clearness of expression, 
and methodical arrangement is better adapted to 
promote a rational conception of dermatology, a 
branch confessedly difficult and perplexing to the 
beginner. — St. Louis Courier of Medicine, April, 
1880. 

The author's task has been well done and has pro- 
daced one of the best recent works upon the difficult 
subject of which ittreats There is no work published 
which gives a better view of the elementary facts 
and pr'nciples of dermatology. — Neio Orleans Medi- 
cal and Surgical Journal, April, 1880. 



H 



YDE (J. NEV1NS), 31. D.. 

Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. 

A PRACTICAL TREATISE ON DISEASES OE THE SKIN. Eor 



the Use of Students and Practitioners In one handsome octavo volume of about 
pages, with numerous illustrations. (In Press.) 



F 



OX ( TILBURF), M.D..F.R.G.P., and T. O. FOX, B.A., M.R.C.S., 

Physician to the Department for Skin Diseases, University College Hospital 

AN EPITOME OP SKIN DISEASES. WITH FORMULAE. For 

Students and Pkactitionkbs. Third Edition, specially revised by the Author, and 
greatly enlarged. In one very handsome 12mo. volume. (Preparing.) 



TfiLINT (A CTSTIN), M.D., 

■*■ Professor of the Principles and Practice of Medicine in Be.llevue Hospital Med. College. N. T. 

A MANUAL OP AUSCULTATION AND PERCUSSION; of the 

Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. 
Third Edition. In one handsome royal 12mo. volume. (Preparing.) 
A notice of the previous edition is appended. 

The little work before us has already become a I author has for m^ny years given, in connection with 
standard one. and has become extensively adopted | practical instruction in auscultation and percussion, 
as a text-book. Thpre is certainly none better. It I to private classes, composed of medical students and 

the I practif 



practitioners. — Cincinnati Med. News, Feb. 



contains the substance of the lessons which 
~DY THE SAME AUTHOR. 

PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- 
ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT- 
MENT AND PHYSICAL DIAGNOSIS ; in a series of Clinical Studies. By Austin 
Flint, M.D., Prof, of the Principles and Practice of Medicine in Bellevue Hospital Med- 
ical College, New York. In one handsome octavo volume of 142 pages. Cloth, $3 50. 



Df THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY 

AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged 
Edition. In one octavo volume of 550 pages, with a plate. Cioth, $4. 

»F THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- 
TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
RESPIRATORY ORGANS. Second and Revised Edition. In one handsome octavo vol- 
ume of 591 pages. Cloth, $4 50. 

jyROWNE (LENNOX), F.R.C.S. Ed., 

-*-' Senior Surgeon to the Central London Throat and Ear Hospital, etc. 

THE THROAT AND ITS DISEASES. Second American, from the 

Second English Edition, thoroughly revised. With one hundred typical illustrations in 
colors, and fifty wood engravings, designed and executed by the author. In one very 
handsome imperial octavo volume of about 350 pages. (Preparing. ) 

VE1LER (CARL), M.D., 

*-J Lecturer on Laryngoscopy at the University of Pennsylvania, Chief of the Throat Dispen- 

sary at thi. University Hospital, Philadelphia , etc. 

A HANDBOOK OF DIAGNOSIS AND TREATMENT OF DISEASES 

OF THE THROAT AND NASAL CAVITIES. Second Edition. In one handsome 
royal 12mo. volume of about 150 pages, with about 50 illustrations. {In Press.) 



WILSON'S STUDENT'S BOOK OF CUTANEOUS 
MEDICINE and Diseases op the Skin. In one 
very handsome royal 12mo volume. Cloth, $3 50. 



HILLIER'S HANDBOOK OF SKIN DISEASES, for 
Students and Practitioners. Second Am Ed. In 
one roval 12mo. vol. of 358 pp, with illustrations. 
Cloth, $2 25. 



2n (Tk.nry C. Lea's Son & Co.'s Publications — ( Venereal Diseaaes^Sb.), 



70RNIL (V.). 

■ r to tht Faculty of Msdieine of Parts, and Physician to the Lourcine ffo»pttal 

SYPHILIS, ITS MORBID ANATOMY, DIAGNOSIS AND TREAT- 
MENT. Specially revised l>y the Author, and translated with note? and ad«! iti. . 
If kniiv C. BlKBS, M.D , Demonstrator of Pathological Ristology in the University of Pen 11- 
i.ia and Surgeon to t he Episcopal Hospital, Philadelphia, and J. William Whitk. 
M.D., Lecturer on Venereal Diseases and Demonstrator of .Surgery in the University of 
Pennsylvania, and Surgeon to the Philadelphia Hospital In one handsome octavo volume 
of I'll page.-, with S4 very beautiful illustrations. Cloth, S3 75. (Just Ready.) 

lion, by giving especial prominence to it* miunt« 
anatomy. The microscopical sections were, a* far as 
possible, made from p irtions of tiss"e removed dnr- 
ing life, m.i as t'> elimiuate appearances due to post- 
mortem change, and excellent drawings of the chief 
lesions are scattered throughout the volume. We 
can stroDgly recommend the work to all who are 
interested in the study of the intimate pathology of 
syphilis. —London Med. Times and Gat., Nov. IS, 



II 



c- i : li the special purp >*e of sliowiu.: 

!' the di-e.sse :i« indicated by b : .~t ..I .> ^ical 

changes da' the author has prep red this volume. 

In iliis respect it i- much hitler than any other we 

conld nam", and merits the clo-e reading of -yphi- 

Th» translation is well done, and the 

will not regret the considerable additions 

which the translators have inserted in the text.— 

Medical aid Surgical Reporter, Aug. •'>, 1 882. 

The original form of lectures has been cbancred 
into chapters in the present issue, and a larire 
amount of additional matter has, with the ooneenl 
o' the author, been inserted by 1 lie translators 
Interpolations deal maiDly with 'he clinical 
- of ihe disease, and contain much valuable 
and well-digested material. Of the series of re- 
searches contained in the present work, it is need- 
less to say that they are worthy of the high reputa- 
tion the author has gained in other branches of 
pathological anatomy. The volume differ* in one 
respect from the many excellent treatises on the 
subject, which have appeared in recent years, both 
in this country, in Fiance and in America, and nip- 
plies a deficiency in the bibliography of _tbe affec- 

RUM STEAD (F. J.), M.D.,LL.D., 

■*-* Late Professor of Venereal Diseases at the 
Coll. of Phys. and Surg., New York, etc 



Tbe characteristic feature of M. Cornil's work in 
the attention piid to the minute anatomy of the 
syphilitic lesions. The histological evolution of the 
various phases of the disease, from the initial chan- 
cre to the gumma, including the mucus patc\ the 
superficial and deep cutaneous eyphilides, tbe osse- 
ous and visceral affections— is considered with a de- 
tail that is in striking contrast to that of other worVs 
upon the same subject. The translation has been 
made wi h his consent and approval, and he is for- 
tunate in the selection of his translators, for they 
hive added materially to the interest and value .f 
the volume —Maryland M.d. Journ., Aug. 15, 1882. 



and 



rPAYLOR{R. W.), A.M.. M.D., 

-*• Professor of Dermatology in t'» l'„i- 



sity of Vermont ; Attending Sur- 
geon to Charity Hospital, etc. 

THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- 
EASES. Including the results of recent investigations upon the subject. Fifth Edition, 
revised and largely rewritten. In one large and handsome octavo volume of about 
900 pages, with about 150 illustrations. (In Press.) 

A few notices of the previous edition are appended. 



We have to congratulate our countrymen upon to America 
the tru'y valuable addition which they have made | 
to American literature. The careful estimate of the I 
v-ilue of the volcme, which we have made, justifies \ 
us in declaring that this is the best iveati-e on 
venereal diseases in the English language, and we I 
might add, if there is a better in any other tongue 
we cannot name it ; there are certainly no books in 
which the student or the general practitioner can 
find snch an excellent risumi of the literature of 
any topic, and such practical suggestions regarding! 
the treatment of the various complications of every ] 
venereal disease. We take pleasure 
tha> we believe this to be the best trea 



dical literature. — Chicago Med. Jour- 
>ial and Examiner, February, 1880. 

It i», without exception, the most valuable single 
work on all branches of the subject of which it Heats 
in any language. The pathology is sound, the work 
is, at the same time, in the highest degree practical, 
*nd the hints that the practitioner will get from it 
for the management of any one case, at all obscure 
or obstinate, will more than repay him for the out- 
lay.— Archives of Medicine, April, 1880. 
It is one of the best general treatises on venereal 
a g ; diseases with which we are acquainted and is espe- 
on veue- cially to be recommended as a guide to the treatment 



real disease in the English iauguage, aud we con- I of syphilis.— London Practitioner, March, 1S80. 
gratnlate. the authors upon their brilliant addition! 

riROSS {SAMUEL W.). A.M., M.D., 

*-* Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Med. College, Phila. 

A PRACTICAL TREATISE ON IMPOTENCE, STERILITY, 

AND ALLIED DISORDEPtS OF THE MALE SEXUAL ORGANS. In one very hand- 
some octavo volume of 166 pages, with 16 illustrations. Cloth, $1 50. (Just Ready.) 

The author has devoted much time to the hardest 
study of this most trying class of diseases, aud this 
labor, together with the fruit of laborious research 
into the scattered literature of the subject, cousti- 
tutes the result of his investigations. We can ear- 
nestly commend it to the practitioner as the very 
t>es! wok upon the subject in the English Ian 
—Nashville Journ. of Med. and Surg., Oct. 1881, 

The author is a clear and coucise writer, and every 



page .i r this treatise gives evidence of his thorough 
familiarity with recent research, and with the latest 
journal literature. The book is a thoroughly scien 
title exposition of our present knowledge of the sub- 
jects treated of; Its p ges are rich in information ..f 
h'gh value to the practitioner, and once rea I, will 
be frequently referred 10.— St. Louis Courier of 
Med., Nov. U531. 



flULLKRIER (A.), and RUMSTEAD {F. J.), MP., LL.D., 

*J Surgeon to the Hdpitatdu Midi. ■*-> late. Professor of Venereal Diseases in the Qot- 

lege of Physicians and Surgeons. N. T 

AN ATLAS OF VENEREAL DISEASES. Translated and Edited l>v 

FrkkmasJ. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns. 

with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 

life. Strongly bound in cloth. $17 00 ; also, in 6 ve parts, stout wrappers . at $3 per part. 

A specimen of the plates and text sent free by mail, on receipt of 25 cents. 
LIE'S LECTURES ON SYPHILIS AND SOME MULL ON SYPHILIS AND LOCAL CONTAGTOPS 
FORMS OP LOCAL DISEASE AFFBOTIHG PBIN- DISORDERS In one handsome octavo volume. 
CIPALLY THE ORGAN'S (>F GENERATION. Iu Cloth, *:j 2.J. 
one handsome octavo volume. Cloth, $2 25. ' 



Henry C. Lea's Son & Co.'s Publications — (Dis. of Children, &c). 21 



SmiTU {J. LE WIS), M.D., 

Clinical Professor of Diseases of Children in the Bellevue Hospital Med. College, N. Y. 

A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF 

CHILDREN. Fifth Edition, thoroughly revised and rewritten. In one handsome oc- 
tavo volume of 836 pages, with illustrations. Cloth, $4 50; leather, $5 50; very hand- 
some half Russia, raised hands, $6. (Just Beady.) 



That a book professing to treat of diseases of chil- 
dren should have reached a fifth edition is in itself 
fair evideuce of its worth, the more especially as it 
has not the field to itself, but has to compete with 
several other excellent manuals. The chapter on 
Rachitis is excellent, and well up to the day— a re- 
mark which may with equal justice he applied to 
the chapter on Scrofula, which is one of the best we 
remember to have read. The diseases of the nervous 
system are well depcribed, and so, for the most part, 
are those of the lungF. Dr. Smith would appear to 
be quite au courant with the work done on this side 
of the world, and refers freely to English and foreign 
authors, as well as to periodicals especially devoted 
to children's diseases. — British Medical Journal, 
May 6, 1882. 

Dr. Smith is a careful observer and painstaking 
writer. He has enjoyed unusual facilities which 
would enable him to write a practical and useful 
book, and that he has succeeded is attested by the 
appearance of successive editions of his work. There 
is no doubt but that it will long retain its place as a 
standard text-book among students and practition- 
ers. — American Journal of Obstetrics, Jan. 18S2. 

There is no book published on the subjects of 



which this one treats that is its equal in value to the 
physician. While he has said just enough to impart 
the information desired by general practitioners on 
such questions as etiology, pathology, prognosis, 
etc., he has devoted more attention to the diagnosis 
and treatment of the ailments which he so accu- 
ral ely describes, and such information is exactly 
what is wanted by the vast majority of "family 
physicians." — Virginia Med. Monthly, Feb. 18S2. 

The appearance of a fifth edition of this work is 
sufficient att*station of its great value to the prac- 
titioners of the country, aud of the use they are 
disposed to make of it. Unquestionably it is the 
best work on the maladies of childhood in the Eng- 
lish language, and in any foreign language we know 
of no work which will compare with it. That the 
fifth edition has been thoroughly revised and 
brought up to date an attentive (or even careless) 
perusal will abundantly disclose. — Canadian Jour- 
nal of Med- Science, Feb. 1882. 

The improvements that have been added bring 
the work fully abreast of the times. We can assure 
oar readers that they can procure no better work 
on infancy aud childhood for reference and study 
than this one. —Cincinnati Med. News, Jan. 1S82. 



K 



EATING {JOHN M.), M.D., 

Lecturer on the Diseases of Children at the. University of Pennsylvania, etc. 

THE MOTHER'S GUIDE IN THE MANAGEMENT AND FEED- 
ING OF INFANTS. In one handsome 12mo. volume of 118 pages. Cloth, $1 00. (Now 
Ready.) 

structing them on the subjects here dwelt upon so 
thoroughly and practically. Dr. Keating has writ- 
ten a practical book, has carefully avoided unne- 
cessary repetition, and, I think, successfully in- 
structed the mother in such details of the treatment 
of her child as devolve upon her; he has studiously 
omitted giving prescriptions, and instructs the mo- 
ther when to call upon the doctor, as his duties are 
totally distinct from hers. — American Journal of 



The title of this little book is well chosen, and Dr. 
Keating has written a work which should be read, 
and its precepts followed by every intelligent mo- 
ther in this country. It is free from all technical 
terms, the language is clear and distinct, and so 
carefully written that it cannot fail to become popu- 
lar. It has always been a mooted question how far 
it is well to instruct the public, but works like this 
one will aid the physician immensely, for it saves 
the time he is constantlygivitig his patients in in- 



Obstetrics.. October 1S81. 



TfAMSBOTHAM [FRANCIS H), M.D. 

THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 
CINE AND SURGERY, in Reference to the Process of Parturition. A new and enlarged 
Edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., 
Professor of Obstetrics, Ac, in the Jefferson Medical College, Philadelphia. In one birge 
and handsome imperial octavo volume of 640 pages, with sixty-four beautiful plates, and 
numerous wood-cuts in the text, containing in all nearly 200 large and beautiful figures. 
Strongly bound in leather, with raised bands. $7 00. 

WEST (CHARLES), M.D~ 

' ' Physician to the Hospital for Sick Children, London, &c. 

LECTURES ON THE DISEASES OF INFANCY AND CHILD- 
HOOD. Fifth American from the Sixth revised and enlarged English Edition. In one large 
and handsome octavo volume of 686 pages. Cloth, $4 50 ; leather, $5 50. 
jgr THE SAME AUTHOR. ( Lately Issued.) 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- 
HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of 
London, in March, 1871. In one volume, small 12mo. Cloth, $1 00. 
_gr THE SAME AUTHOR. 

LECTURES ON THE DISEASES OF WOMEN. Third American, 

from the Third London Edition. In one octavo volume of about 550 pages. Cloth, 

$3 75; leather, $4 75. 
INCKEL (F.). 
A COMPLETE TREATISE ON THE PATHOLOGY AND 

TREATMENT OF CHILDBED, for Students and Practitioners. Translated, with 
the consent of the author, from the Second German Edition, by Jambs Read Chadwick, 
M.D. In one octavo volume of 484 pages. Cloth, $4 00. 



w 



SMITH'S PRACTICAL TREATISE ON THE WAST- 
ING DISEASES OF INFANCY AND CHILDHOOD. 



Second American, from the Second English Edi- 
tion. In one octavo volume. Cloth., $2 50. 



22 Henry C. Lea's Son A Co.'s Publications — (Dis. of Women). 



rpHOMAS (T. GAILLARD.M.D., 

■*- Pr«fe&80r of Obstetrics, 6c, in tht College of Physicians, and Surgeon*, A T . F., Ac 

A PRACTICAL TREATISE OX THE DISK ASKS OF WOMEN. Fifth 

Edition, thoroughly revised and rewritten. In one large and handsome octavo volume 

of 810 page?, with 260 illustrations. Cloth, $5; leather, $6 ; very handsome half 

Russia, raised hands, $ti 50. (Now Ready.) 

The w..rJs which follow "fifth edition" are in This work needs no introduction to any of the 

a o mere formal announcement. The alter- civilized nations of the world. The edition before 

ations and addition* which have been made ate both ns adds to the strength of former volumes. With 

numerous and important. The attraction and the the wisd >m of a master teacher he here gives the 

permanent rharicter of this hook lie in the clear- results that, in his judgment, are most trustworthy 

ness and trnth of the clinical descriptions of dis- at the present time. In its own place it has no 

I he fertility of the author In therapeutic re- rival, because the author is the best teacher on this 

- and the fulness with which the details of subject to the masses of the profession As hitherto 

treatment are described ; t lie definite cluran *x of this work will be l lie text-hook on diseases of wo- 

the teaching; and la-t. hit not least, the evident men We only wish that in other branches of medi- 

candor which pervades it We won Id aKo partlca- cine a- capable teachers Could be found to write our 

iarize the fulness with which the history of the sub- text-books. — Detroit Lancet, Jan 188L 

gone into wbich makes the book addition- i r t ha« been enlarged and carefully revised. The 
ally Interesting and gives ,t value as a work of anth or has brought it fnllv abreast "with the times, 
reference.— London Med. Times and Oat., July oO, and a8 the ware of ^narcological progression has 
188 *' been widespread and rapid during the twelve years 
An examination of the work will prove that it is that have elapsed since the issue of the first edition, 
one of great merit. It i- not a mere compilation oue can conceive of the gr-at improvement this edi- 
from other works, but is the fruit of the ripe tion must be upon the earlier. It is a condensed en- 
thought, sound judgment, and critical observations cyclopaedia of cynsecological medicine. The style of 
of a leirned, scientific man. It is a treasury of arrangement, the maiterly manner in which each 
knowledge of the department of medicine to which subject is treated, and the honest convictions de- 
it is devoted In its present revised state it cer- rived from probably the largest clinical experience 
talnly hold" a foremost position as a gynecological in that specialty of any in this country, all serve to 
work, and will continue to be regarded as a stan- commend it in the highest terms to the practitioner, 
d.ird authority —Cincinnati Med. News, Dec 1880. — Nashville Jnum. of Med. and Surg., Jan. 1SS1. 



n YNE CO L TCA L Til A NSA G TIO NS. 

*■>* Being the Transaction* of the American Gynecological Society for the Year 1881. 

VOLUME VI. (Just Ready) Contains Essays by Doctors W. H. By- 
ford, S C. Busev, H. J. Garrignes. G. H. Lyman. Nathan Bozeman, E. Van de War- 
ker, I. E. Taylor, W. Goodell,"n. F. Campbell, T. G. Thomas T. A. Rearuv. A. H. 
Smith. A D. Sinclair, J. \V. Underhill, E. W. Jenks, LL.D., W. M. Polk. W. R. Gillette, 
C. C. Lee, F. P. Foster, B. W. Sawyer and B. B. Browne. 

With Indexes of Vol VI., of the Gynecological and Obstetric Literature of all Coun- 
tries for the Year 18S0, of Obstetric and Gynecological Journals, and of Obstetric and 
Gynecological Societies. 

The six volumes completing the series will be sent by mail postpaid on receipt of ?30, 
or if single copies are desired they will be furnished at the rate of $5 each, excepting 
Vol. II. for the year 1877, the price of which is $6.50. 

JPDIS {ARTHUR W.),M.D. Lond., F.R.C.R, M:R.O:S., 

-*-' desist. Obstetric Physician to Middlesex Hospital, late Physician t<> British Lying-in Hospital. 

THE DISEASKS OF WOMEN. Including their Pathology, CttlSa- 
tion, Symptoms, Diagnosis and Treatment. A manual for Students and Practitioners. 
In one handsome octavo volume of 576 pages, with 148 illustrations. Cloth, §3 ; leather, 
$4. (Jitst Ready.) 
It is a pleasure to read a book so thoroughly good ' The greatest pa'us have been taken with the see- 
as this one. The speciU qualities which are con- tlons relating to treatment. A liberal selection of 
spicuous are thoroughness in covering the whole remedies is given for each morbid condition, the 
ground, clearness of description, and conciseness of streugth, mode of application, and other details 
siatement. Another marked feiture of the b iok is being fully explained. The descriptions of eynaco- 
tl.e attention paid to the deails of many minor sui- logical manipulations and operations are full, clear, 
gical operationsand procedures, a^, for instance the and practical. Much care has also been bestowed 
use of tents, application of leeches, and use of hot- on the parts of the book which deal with diagnosis : 
water injections. These are among the m >re com we note especially the pages dealing with the dif- 
inon methods of treatment, and yet very little is ferentiation, one from another of the different kinds 
said about them in many of the text-books. The of abdominal tumors. The practitioner will there- 
book is one to be warmly recommended, e-peci illy to fore find in this book the kind of knowledge be most 
students and general practitioners, who need a con- needs in his daily work. and he will be pleased w th 
ci-e but complete resume of the whole subject. Spe- theclea-n*»s» and fnlnass of th« information there. 
cia i-t-. too. will fiud many useful hints iu its pages given.— The Practitioner, Feb. 1882. 
—Boston M>d and Surg. Journ , March 2, 1888. 



B 



H 



ARNES (ROBERT). 31. D., E.R.C.P., 

Obstetric Physician to St. Thomas' Hospital, *c. 

A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- 
CAL DISEASES OF WOMEN. In one handsome octavo volume, with numerous 
illustrations. {New Edition Preparing.) 

ODOE {HUGH L.), M.D., 

Emeritus Profi vsor of Obstetrics, &c, in the University of Pennsylvania. 

ON DISEASES PECULIAR TO WOMEN: including Displacements 

of the Uterus. Second Edition, revised and enlarged. In one beautifully printed 
octavo volume of 5 19 pages, with original illustrations. Cloth, $4 50. 



Henry C. Lea's Son & Co.'s Publications — (Dis.of Women). 



23 



ffMMET {THOMAS ADDIS), M.D., LL.D., 

-*-J Surgeon to the Woman's Hospital, New York, etc. 

THE PRINCIPLES AND PRACTICE OF GYNAECOLOGY, for the 

use of Students and Practitioners of Medicine. Second Edition. Thoroughly Revised. 
In one large and very handsome octavo volume of 879 pages, with 133 illustrations. 
Cloth, $6; leather, $6 ; half Russia, raised bands, $6 50. (Just Issued.) 



In no country of the world bas gynecology re- 
ceived more attention thanin America. It is, then, 
with a feeling of pleasure that we welcome a work 
on diseases of women from so eminent a gynecolo- 
gist as Dr. Emmet. The work is essentially clini- 
cal, and leaves a strong impress of the author's in- 
dividuality. To criticize, with the care it merits, 
the book throughout, would demand far more space 
than is at our command. In parting, we can say 
that the work teems with original ideas, fresh and 
valuable methods of practice, and is written in a 
clear and elegant style, worthy of the literary repu- 
tation of the country of Longfellow and Oliver Wen- 
dell Holmes.— Brit. Med. Journ. Feb. 21, 18S0. 

No gynecological treatise has appeared which 
contains an equal amount of original and useful 
matter; nor does the medical and surgical history 
of America include a book more novel and useful. 
The tabular and statistical Information which it 
contains is marvellous, both in quantity and accu- 
racy, and cannot be otherwise than invaluable to 
future investigators. It is a work whi ch demands 



not careless reading but profound study. Its value 
as a contribution '0 gynecology is, perhaps, greater 
than that of all previous literature on the subject 
combined. — Chicago Med. Gaz., April 6, 1880 

The wide reputation of the author makes its pub- 
lication an event in the gynecological world ; and 
a glance through its pages shows that it is a work 
to be studied with care. . . . It must always be a 
work to be carefully studied and frequently con- 
sulted by those who practise this branch of our pro- 
fession.— Lond. Med. Times and Gaz., Jan. 10, 18S0. 

The character of the work is too well known to 
require extended notice — suffice it to say that no 
recent work upon any subject has attained such 
great popularity so rapidly. As a work of general 
reference upon the subject of Diseases of Women i' 
is invaluable. As a record of the largest clinical 
experience and observation it has no equal. No 
physician who pretends to keep up with the ad- 
vances of this department of medicine can afford to 
be without it. — Nashville Journ. of Medicine and 
Surgery, May, 1880. 



N AMERICAN SYSTEM OF GYNECOLOGY. 



A SYSTEM OE GYNECOLOGY IN TREATISES BY VARIOUS 

AUTHORS. (In Active Preparation.) 

nUNCAN {J. MATTHEWS), M.D., LL.D., F.R.S.E., etc. 

CLINICAL LECTURES ON THE DISEASES OF WOMEN, 

Delivered in Saint Bartholomew's Hospital. In one handsome octave volume of 175 
pages. Cloth, $1 50. (Just Issued.) 

stamp of individuality that, if widely read, as they 



They are in every way worthy of their author ; 
indeed, we look upon them as among the most valu- 
able of his contributions. They are all upon mat- 
ters of great interest to the general practitioner. 
Some of them deal with subjects that are not, as a 
rule, adequately handled in the text-books ; others 
of them, while bearing upon topics that are usually 
treated of at length in such works, yet bear such a 



certainly deserve to be, they cannot fail to exert a 
wholesome restraint upon the undue eagerness with 
which many yoangphysicians seem bent upon fol- 
lowing the wild teachings which so infest thegyne- 
cology of the present day. — N. T. Med. Journ., 
March, 1880. 



T 



O 



Q 



?ARRY (JOHN S.), M.D., 

Obstetrician to the Philadelphia Hospital, Viee-Prest. of the Ohstet. Society of Philadelphia . 

EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, 

DIAGNOSIS, PROGNOSIS AND TREATMENT. In one handsome octavo volume 
of 272 pages. Cloth, $2 50. 

ANNER {THOMAS H.), M.D. 

ON THE SIGNS AND DISEASES OF PREGNANCY. First American 

from the Second and Enlarged English Edition. With four colored plates and illustra- 
tions on wood. In one handsome oetavo volume of about 500 pages. Cloth, $4 25. 

1USSEROW {A.), 

Professor of Midwifery and the Diseases of Children at the University of Berlin. 

A PRACTICAL TREATISE ON UTERINE TUMORS. Specially 

revised by the Author, and translnted with Notes and Additions by Edmund C. Wendt, 
M D., Pathologist to the St. Francis Hospital, N. Y., etc., and revised by Nathan 
Bozeman, M.D., Surgeon to the Woman's Hospital of the State of New York. In one 
handsome octavo volume, with about 40 illustrations. (Preparing.) 

HAD WICK (JAMES R.), A.M., M.D. 

A MANUAL OF THE DISEASES PECULIAR TO WOMEN. In one 

handsome royal 12mo. volume, with illustrations. (Preparing.) 



ASHWELL'S PRACTICAL TREATISE ON THE DIfc 
EASES PECULIAR TO WOMEN. Third American 
from the Third and revised London Edition. In 
one 8vo. vol., pp. 528. Cloth, $3 50. 

CON DIE'S PRACTICAL TREATISE ON THE DIS- 
EASES OF CHILDREN. Sixth Edition, revised 
and augmented. In one large octavo volume oi 
nearly 8f0 ciosely-printed pages Cloth, $6 26 : 
leather, $6 25. 



JHURCHILL ON THE PUERPERAL FEVER AND 
OTHER DISEASES PECULIAR TO WOMEN. In 
one octavo volume of 150 pages. Cloth, $2 50. 

MEIGS ON THE NATURE, SIGNS AND TREAT 
MENT OF CHILDBED FEVER In one 8vo. vol. 
pp. 316. Cloth, $2 00. 

MONTGOMERY'S EXPOSITION OF THE SIGNS 
4.ND SYMPTOMS OF PREGNANCY. With two 
exquisite colored plates, and numerous wood cuts. 
In one vol. 8vo., of nearly 600 pp. Cloth, $3 76. 



24 Henry C. Lea's Son & Co.'s Publications — (Midwifery). 

7 EISHMAN ( WILLIAM). M.D., 

>*"' R-gius Prof, ssor •>/ Midwifery in the University of Glasgow. Ac. 

A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF 

PREGNANCY AND THE PUERPERAL STATE. Third American Edition, revi-ed by 

the Author, with additions by John S. Parry, M.D., Obstetrician to ihe Philadelphia 

Hospital, "fcc. In one large and very handsome ootnvo volume, of 740 pages, with 2(15 

illustration?. Cloth, $4 50; leather, $5 50 ; half Russia, $6. (Just Issued ) 

Few works on this subject have met with as great »»m« to require, and we cannot but admire the 

a demand as this one appears to have. Tojndge ability with which the task has been performed. 

by thf frequency with which its author's views are We consider it an admirable text-book for students 

qn >ted, and its statements referred toin obstetrical I daring their attendance upon lectures, and have 

literal are, one would judge that there are fewphy- ' great pleasure in recommending it. As an exponent 

derating much attention to obstetrics wno , of th» midwifery of the present day it has no supe- 

are without it. The author is evidently a man of rior in the English language. — Canada Lancet, Jan. 

ripe experience and conservative views, and in no 1580. 

inch of medicine are these more valuable than in j Tn the American stndpnt the work before us mast 



I >, . _.v, „• BemediM, Jan prove admirably adapted, complete in all Its parte, 

We gladly welcome the new edition of this excel- j esspntially modern in its teachings and with dem- 
Ipnt text-book of midwifery. The former editions | on«trations noted for clearness and precision it will 
have been most favorablyreceived by the profes- ! gain in favor and be recognized as a work or stand- 
Bion on both sides of the Atlantic In the prepara- ard merit. The work cannot fail to be popular, and 
t -I, of the present edition the author has made such is cordially recommended.— N. 0. Med. and Surg. 
alterations as the progress of obstetric -.1 science Journ., Ma rch, 1SS0. 

pLA YFAIR ( W. S.), M.D., F.R.C.P.. 

-*■ Pr ofe an or of Obstetric Medicine in King's College, etc. etc. 

A TREATISE ON THE SCIENCE AND PRACTICE OF MIDWIFERY. 

Third American Edition, revised by the author. Edited, with addition?, by Robkrt P. 

Harris. M.D. In one handsome octavo volume of 659 pages, with 133 illustrations. 

Cloth, $4; leather, $5; half Russia, $5 50. (Just Issued.) 
The medical profession has now the opportunity i of the estimate that the profession has formed of it. 
of adding to their stock of standard medical works It is indeed so well known and so highly valued 
oneofthehest volmneson midwifery ever published, that nothing need be said of it as a whole. All 
The subject is taken up with a master hand. The things considered, we regard this treatiseas the very 
part devoted to laborin all its variouspresentations, best on Midwifpry in the English language.— N. Y. 
the management and results, is admirably arranged, Medical Journal, May, 1880. 

and the views entertained will be found"essentially it certainly is an admirable exposition of the 
modern, and th» opinions expressed trustworthy Science and Practice of Midwifery. Of course the 
The work abounds with plates, illustrating various additions made by the American editor, Dr. R. P. 
oh-tetrical positions; they are admirably wrought, Harris, who never utters an idle word, and whose 
and afford great assistance to the student. — N. 0. studious researches in some special departments of 
Me<i. and Surg. Journ., March, 1S80. obstetrics are so well known to the profession, are 

The rapidity with which one edition of this work of great value.— The American Practitioner. April, 
follows another is proof alike of its excellence and ISSu. 
JD Y THE SA ME A UTHOR. 

THE SYSTEMATIC TREATMENT OF XERYE PROSTRATION 

AND HYSTERIA. In one handsome volume, small 12mo. {In a few days.) 

TfLXf; (A. F. A.), M.D., 

-*■*- Prnfessdr nf Obstetrics and D 'senses of Women in the Mediral Depart men. of the Columbian 

University, Washington, D.C., and in the University of Vermont, &c. 

A MANUAL OF OBSTETRICS. In one very handsome 12mo. vol- 
ume of 321 pages, with 58 illustrations. Cloth, $2. (Just Ready.) 
Though the book appears small externally, it I tionary, and well suited to the student, it is also of 
contains as complete a consideration of obstetric valne to the general practitioner, who often desires 
subjects as mauy larger volumes, and this is chiefly to find a risumt of information upon a given 
owing to a directness of expression, and an avoid- ' subject. It will be of further value to the latter, as, 
ance of repetition, and of waste of words. The au- in our opinion, the author holds most sensible views 
Ihor endeavors to place theories, causes of disease, on practical matters. The book is admirably ar- 
and meth'ds of treatment in that order which, by i ranged for reference, beiDg well paragraphed, with 
weight of authority, they merit. His excellent suitable subdivisions, and well indexed. — American 
judgment has availed him well in this effort. While, Journal of Obstetrics, Aug. 1882. 
|U one sense, the book is an excellent obstetric die- ' 

PA R VIN ( THE PHIL US) . M. I) . , " 
I'rf of obstetrics and of Ihe Med. and Surg. Diseases of Women in the Med. Coll. of Indiana. 

A TREATISE ON MIDWIFERY. In one very handsome octavo 

volume of about 550 pages, with numerous illustrations. (Preparing.) 
J)ARNES (FANCOURT), M.l>.. 

J~* Physician to the Genera I Lying-in Hospital, London. 

A MANUAL OF MIDWIFERY FOR MIDWIYES AND MEDICAL 

STUDENT8. With 50 illustrations. In one royal 12mo. volume of 200 pages. Cloth, 
$1 25. (Lately Issued.) 

LJODGE {HUGH L.), M.D~ 

*■■*■ Emeritus Professor of Midwifery, Ac.,inthe University of Pennsylvania, Ac . 

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illns- 

trated with large lithographic plates containing one hundred and fifty-nine figures from 
original photogrnphs, and with numerous wood-cuts. In one large and beautifully printed 
quarto volume of 550 double-columned pages. Strongly bound in cloth. $14. 
**# Specimens of the plate? and letter-press will be forwarded to any address, free by mail, 
on receipt of six cents in postage stamps. 



Henry C. Lea's Son & Co.'s Publications— (Surgery). 



25 



TJAMILTON {FRANK H.), M.D., LL.D., 

J--t- Surgeon to the Bellevue Hospital , New York. 

A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 

TIONS Sixth Edition, thoroughly revised, and much improved. In one very handsome 
octavo volume of 909 pages, with 352 illustrations. Cloth, $5 50; leather, $6 50; half 
Russia, raised bands, $7 00. {Just Issued.) 



So many kind expressions of welcome have been 
showered upon each successive edition of this val- 
uable treatise, that scarcely anything remains for 
us to do but to extend the customary cordial greet- 
ing. It is the only complete work on the subject 
of Fractures in the English language. "We con- 
gratulate the accomplished author on the deserved 
success of his work, and hope thai he may live to 
have many succeedingeditions passunderhis skilled 
supervision. — Coll. and Clin. Rec, Nov. 15, I860. 

Universal verdict has pronounced it, humanly 
speaking, a perfect treatise upon this subject. As 
it is the only complete and illustrated work in any 
language treating of fractures and dislocations, it 
is safe to affirm that every wide-awake surgeon and 
general practitioner will regard it as indispensable 
to the safe and pleasaDt conduct of their prefes- 
sional work.— Detroit Lancet, Nov. 18, 1S80. 



Dr Hamilton has devoted great labor to thextndy 
of these subjects. His large experience, extended 
research, and patienr investigation have made him 
one of the highest authorities among living writers 
in this branch of surgery. This work is systematic 
and practical in its arrangement, and presents its 
subject matter clearly and forcibly to the reader 
or student. — Maryland Med. Journ., Nov. 15, 1880. 

The only complete work on its subjectin the Eng- 
lish tongue, and, indeed, may now be said to be 
the only work of its kind in any tongue. It would 
require an exceedingly critical examination to de- 
tect in it any particulars in which it might be im- 
proved. The work is a monument to American 
surgery, and will long serve to keep green the 
memory of its venerable author.— Michigan Med. 
News, Nov. 10, 18S1. 



A SHHUBST {JOHN, Jr.), M.D., 

•£*- Prof, of Clinical Surgery, Univ. of Pa. , Surgeon to the Episcopa I Hospital, Philadelphia. 

THE PRINCIPLES AND PRACTICE OF SURGERY. Third 

Edition, enlarged and revised. In one very large and handsome octavo volume of 10U0 

pages, with 555 illustrations. Cloth, f " 

raised bands, $7 50. {Just Ready.) 
The author, long known as a thorough student of 
surgery, and one of the most accomplished scholars 
in the country, aims to give in this work "a con- 
densed but comprehensive description of the modes 
of practice now generally employed in the treatment 
of surgical affections, with a plain exposition of the 
principles upon which these modes of practice are 
based."' In this he has so well succeeded that it 
will be a snrprise to the reader to know how much 
practical knowledge extending over such a wide 
range of research is compressed in a volume of 
this size. This feature of the work must be its 
best claim for continued popularity with students 



: leather, $7 ; very handsome half Russia, 

and practitioners. In fact, in this respect it is with- 
out any equal in any language. In the present edi- 
tion many novelties in surgical practice are intro- 
duced, many modifications of previous statements 
made, and several new illustrations added. — Med. 
Record, Nov. 18, 1882. 

A good student's book, thoroughly reliable, brief, 
and to the point, abundantly illustrated. The posi- 
tion in medical literature of Ashhurst's Surgery 
needs only the announcement of the appearance of 
a ne«v edition without an extending notice of its 
peculiar merits.— CA'ege and Clinical Record, Nov. 
15, 1882. 



pO BERTS (JOHN B.), A. ill., M.D., 

-*-*•' Lecturer on Anatomy and on Operative Surgery at the Philadelphia School of Anatomy, Fellow 
of the Philadelphia, Academy of Surgery, etc. 

THE PRINCIPLES AND PRACTICE OF SURGERY. For the 

Use of Students and Practitioners of Medicine and Surgery. In one very handsome 
octavo volume of about 500 pages, with many illustrations. {Preparing.) 

OTIMSON {LEWIS A.), B.A., M.LX, 

*3 Professor of Pathological Anatomy at the University of the City of New York, Surgeon and Cura- 
tor to Bellevue Hospital, Surgeon to the Presbyterian Hospital, New York, etc. 

A PRACTICAL TREATISE ON FRACTURES. In one very hand- 
some octavo volume of 582 pages, with 360 beautiful illustrations. Cloth, $4 75 j 
leather, $5 75. (Just Ready.) 
In the preparation of this volume the author has aimed to present a treatise on fractures 
which should by means of terseness of expression and perspicuity of arrangement, give a full 
and satisfactory exposition of its subject within convenient compass. The opening chapters 
discuss the varieties of fractures, their causes, diagaosis and method of repair, their complica- 
tions, remote oonsequences and treatment, delayed, deformed, faulty or vicious union, and 
general prognosis. The fractures of the various parts of the body are then tafcen up in regular 
order, and their causes, diagnosis, prognosis and treatment are considered with exceptional ful- 
ness. The series of illustrations is large and remarkable for beauty and accuracy. 
T> Y THE SAME A UTHOR. ' 

D A MANUAL OF OPERATIVE SURGERY. In one very handsome 

royal 12mo. volume of about 500 pages, with 332 illustrations ; cloth, $2 50. 
The work before us is a well printed, profusely performing them. The work is handsomely illns- 
lllastrated manual. The novice, by a perusal of the , trated, and the descriptions are clear and well drawn, 
work, will gain a good idea of the general domain of It is a clever and useful volume; every student 
operative surgery, while the practical surgeon has \ should possess one. The preparation of this work 
presented to him within a very concise and intelli- j does away with the necessity of pondering over 
gible form the latest and most approved selections of larger works on surgery for descriptions of opera- 
operative procedure. The precision and conciseness | tions, as it presents in a nut-shell just whatis wanted 
with which the different operations are described j by the surgeon without an elaborate search to find 



enable the author to compress an immense amount 
of practical information in a very small compass. — 
N. Y. Medical Reaord, Aug. 3, 1878. 

This volume is devoted entirely to operative sur- 
gery, and is intended to familiarize the student with 
the details of operations and the different 



it.— Md. Med Journal, Aug. 1878. 

The author's conciseness and the repleteness of 

the work with valuable illustrations entitle it to be 

classed with the text-books for students of operative 

surgery, and as one of reference for the practitioner. 

of \ — Cincinnati Lancet and Clinic, July 27, 1878. 



26 TTenry C. Lea's Son <fe Co.'s Publications — (Surgery). 

(1R0S8 (SAMUEL D.), M.D., LL.D.. D.C.L.. Oxon., LL.D., Cantab. 

^-" F.utiritH* °roft ttor "/ Surgery in the Jeff>rson Me.dical College of Philadelphia . 

A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic 

and Operative Sixth Edition, greatly enlarged and thoroughly revised by the Author 
and Samtel \V. Gross, A.M., M.D., Professor of the Principles of Surgery and of Clini- 
cal Surgery in the Jefferson Medical College. In two large and beautifully printed impe- 
ril OOtaTO volumes containing 2382 pages, illustrated by 1023 engravings Strongly 
bound in leather, raised bands, $15; half Russia, raised bands, $16. (Jntt Ready ) 
Extract from Preface to the S:xtii Emtio*. 
The object of this work, a* set forth in the first edition, issued in 1859, is to furnish a sys- 
tematic and comprehensive treatise on the art and science of surgery, considered in the broad- 
est sense; one that shall serve the practitioner as a faithful and available guide in his daily 
routine of duty. My aim has been to embrace the whole domain of surgery, and to allot to 
every subject its legitimate claim to notice in the great family of external diseases and acci- 
dents. Special attention has also been bestowed upon the discrimination of diseases; and an 
elaborate chapter on general diagnosis has been introduced. Upon the edition now issued 
much time and labor have been expended, rendered necessary by the astonishing progress 
made during the last ten years in every branch of surgery. Every chapter has been thoroughly 
revised, many portions have been entirely rewritten, and a large amount of new matter has 
been introduced, in order to place the work fully abreast of the existing state of our knowledge. 
Td6 work as a whole needs no commendation. . English language It is a treatise upon surgery 
Many years ag> itearcel for Itself the enviable re- that is really encyclopedic in its character as re- 
putation of the leading American work on surgery, gards fully treating every topic of the science, and 
and it is still capable of maintaining that standard, j minutely detailing all that is known in regard to it. 
Tue reason for this need only to be mentioned to be ! There is scarcely a department to which he has not 
appreciated. The author has always been calm and I either added something, or elucidated better that 



juuicious in his statements, has based his concli 

-ions on much study aud personal experience, has 

been able to grasp his subject in its entirety, and, 

-.11, has cousciet tiously adhered to truth and 



which was already known. Without stopping to 
record actual discoveries we can truly say that his 
learning, experience and research, more than that 
of almost auy other great surgeon, has elevated snr- 



t-ict, weighing the evidence, pro and con, accord- l gery to the high pinuacle which it has attained. In 
iugly. a considerable auiouut of new material has : the sixth edition of this great work every chapter has 
beu introduced, and altogether the distinguished j been thoroughly revised, many poriions have been 
author Las reason to be satisfied that he has placed entirely rewritten and a large amount of new matter 
the work fully abreast of the state of our knowl- | has been introduced in order to place the work fully 
edge. — Medical Record, iNov. IS, 18S2. | abreast of the existing state of our knowledge. — 

This great work by Professor Gross is undoubt- j Cincinnati Xed. .Veto*, Nov. 18S2. 
edly the most magnificent work upon surgery in the 
T>Y THE SAME AUTHOR. 

A PRACTICAL TREATISE OX THE DISEASES, INJURIES 

and Malformations of the Urinary Bladder, the Prostate Gland and the Urethra. Third 
Edition, thoroughly revised and much condensed, by Samuel W. Gross, M.D., Sur- 
geon to the Philadelphia Hospital. In one handsome octavo volume of 574 pages, with 
170 illustrations. Cloth, $4.50. 



For retereuceaiiugeueral iniormatiou, the physician 
or surgeon can find no work that meets their necessitief 
more thoroughly than this, a revised edition of an ex- 
cellent treatise, and no medical library should be with- 
out it. Replete with handsome illustrations and gooo 
ideas, it has the unusual advantage of being easil) 



■-omprehended.by the reasonableand practical manner 
ia which the various subjects are systematized and 
trranged We heartily recommend It to the profession 
1= a valuableadditionto theimportantliteratureofdis- 
easesot'the urinary organs. — Atlanta Med -Jour n., Oct. 
1876. 



J)Y THE SAME AUTHOR 

A PRACTICAL TREATISE ON FOREIGN BODIES IN THE 

AIR-PASSAGES- In 1 vol. 8vo., with illustrations, pp. 452 Cloth, $2 75. 
flOLEMAN {ALFRED), L.R.C7P~ F.R.C.S., Exam. L.D.S.,etc. 

^ Senior Dental Surgeon and Lecturer on Dental Surgery to St. Bartholomew's Hospital and the 
Dental College of London. -, ~ - ~. >.V*> 

A MANUAL OF DENTAL SURGERY AND PATHOLOGY. 

Thoroughly revised and adapted to the use of American students, by Thomas C. Stell- 

wagen, M.A., M.D., D.D.S., Prof, of Physiology at the Philadelphia Dental College. In 

one handsome volume of 412 pages, with 331 illustrations. Cloth, $3 25. {Just Ready.) 

This volume presents a highly creditable appear- I There have been added to the volume a hundied 

ance and destrvts to rank among the most important pages by the American eoitor. embodying the views 

of recent contributions to dental literature. Mr. of the leading home teachers in denial surgery. The 

Coleman has presented his methods of practice, for work, therefore may be regarded as stricily abreast 

the most part, in a plain aDd concise manner, and wiih the times, aud as a very high authority on the 

the work of the American editor cas been conscien- I subjeel of which it treats.— Amer. Prac, July, 1S82. 



tiously performed. He has evidently labored to pre- 
»ent his convictions of the best modes of practice for 
Ihe instruction of those commencing a professional 
career, and he has faithfully endeavored to teach to 
oihers all that he has acquired by his own observa- 
tion aud experience. The book deserves a place in the 
library of every dentist. — Dental Cosmos, May, 18S2. 
Ihe author brings to his task a large experience 
acquired under the most favorable circumstances. 

SCROFULA AND ITS GLAND DISEASES. 

& An Introduction to the General Pathology of Scrofdla, with an Account of the 
Histology, Diagnosis and Treatment of its Glandular Affbctions. By Fred- 
erick Treves, F.R.C.S. Eng., Assistant Surgeon to and Senior Demonstrator of 
Anatomy at the London Hospital. Complete in one octavo volume. In paper 
covers. Price, 10 cents. 



It should be in the possession of eveiy practitioner 
in this country. The part devoted to first and second 
dentition and'irregularities in the permanent teeth 
is fully worth the price. In fact, price should not 
be considered in purchasing such a work. If the 
money put into some of our so-called standard text- 
books could be converted into such publications as 
this, much good would result.— Southern Dental 
Journal, May, 1882. 



Henry C. Lea's Son & Co.'s Publications — (Surgery). 27 

TJOLMES (TIMOTHY), 31. A., 

J-J- Surgeon and Lecturer on Surgery at St. George's Hospital, London. 

A SYSTEM OF SURGERY; THEORETICAL AND PRACTICAL. 

In Treatises by various authors. American Edition, Thoroughly revised and 
re-edited by John H. Packard, M.D., Surgeon to the Episcopal and St. Joseph's Hospi- 
tals, Philadelphia, assisted by a large corps of the most eminent American surgeons. In 
three large and very handsome imperial octavo volumes containing 3137 douMe-columned 
pages, with 979 illustrations on wood and thirteen lithographic plates, beautifully colored. 
Price per volume, cloth, $6 00 ; leather, $7 00 ; half Russia, $7 50. Per set, cloth, 
$18 00 ; leather, $21 00; half Bussia, $22 50. (Sold only by subscription.) 
Volume I. (now ready) contains General Pathology, Morbid Processes, Injuries in 

General, Complications of Injuries and Injuries op Regions. 
Volume II. (now ready) contains Diseases of Organs of Special Sense, Circulatory 

System, Digestive Tract and Genito-urinary Organs. 
Volume III. (just ready) contains Diseases of the Respiratory Organs, Bones, Joints 
and Muscles, Diseases of the Nervous System, Gunshot Wounds, Operative and 
Minor Surgery, and Miscellaneous Subjects (including an essay on Hospitals). 
This great work, issued some years since in England, has won such universal confidence 
wherever the language is spoken, that its republication here, in a form more thoroughly 
adapted to the wants of the American practitioner, has seemed to be a duty ow.ng to the pro- 
fession. 

To accomplish this, the aid has been invited of thirty-three of the most distinguished gentle- 
men, in every part of the country, and tor more than a year they have been a.-siduously engaged 
upon the task. Each article has been placed in the h;inds of a gentleman specially competent 
to treat its subject, and no labor has been spared to bring each one up to the foremost level of 
the times, and to adapt it thoroughly to the practice of the country. In certain cases, this 
has rendered necessary the substitution of an entirely new essay for che original, as in the case 
of the articles on Skin Diseases, and on Diseases of the Absorbent System, where the views of 
the authors have been superseded by the advance of medical science, and new articles have 
therefore been prepared by Drs. Arthur Van Harlingen and S C. Busey, respectively. So 
also in the case of Anaesthetics, in the use of which American practice differs from that of Eng- 
land, the original has been supplemented with a new essay by J. C. Reeve, M.D., treating 
not only of the employment of ether and chloroform, but of the other anaesthetic agents of 
more recent discovery. The same careful and conscienti us revision has been pursued through- 
out, leading to an increase of nearly one-fourth in matter, while the series of illustrations has 
been nearly trebled, and the whole is presented as a complete exponent of British and Ameri- 
can Surgery, adapted to the daily needs of the working practitioner 

In order to bring it within the reach of every member of the profession, the five volumes of 
the original have been compressed into three, by employing a douole-columned imperial octavo 
page, and in this improved form it is offered at less than one half the price of the original. It 
is beautifully printed on handsome laid paper and forms a worthy companion to Reynolds' 
System of Medicine, which has met with so much favor in every section of the country. 

The work will be sold by subscription only, and in due time every member of the profession 
will be called upon and offered an opportunity to subscribe. 

It is a subject for congratulation that the ide-i of 
an American edition, incorporating all recently ac- 
quired knowledge and experience, should have" 



mceived, and its execution intrusted to such able 
hands as Packard's. The names of coadjutois in 
the edition of the 1st volume, which has come to 
hand, afford a sufficient guarantee t»at the work has 
not only been brought fully up to date, but also thtt 
it his been accomplished in that large, thorough, 
and scientific spirit which characterized the contri- 
butions to the original edition. — (Jan. Journ. of 
Med. Science, Nov. 1881. 

The authors of the original English edition are 
men of the front rank in England, and Dr. Packard 
has been fortunate in securing as his American co- 
adjutors such men as Bartholow, Hjde, Hunt, Con- 
ner, Stimson, Morton, Hodgen, Jewell and their 
colleagues. They have revised and added to all the 
articles except three, whiuh were found so complete 
as not to require any additions. The new matter 
varies considerably in amount and character, but is 
always judicious and useful, in some cases it is very 
Blight, while in oihers the additions are large in 
amount and radical in character. As a whole, the 
work, if we may judge by this first volume, will be 
solid and substantial, and a valuable addition to the 
library of any medical man. It is more wieldy and 
more useful than the five volume English edition; 
and with its companion work — "Reynolds' System 



of Medicine" — will well represent the present state 
of our science. One who is lamiliar with those two 
works will be fairly well furnished head-wise and 
hand-wise.— The Medical News, Jan. 7, 1882. 

Great credit is due to the American editor and his 
co-laborers for revising and bringing within easy 
reach of American surgeons, a work wtiich has been 
received with such universal tavor on the o;her side 
of the Atlantic as Holmes' System of Surgery. In 
the list of English contributors to the first volume, 
we find ihe nimes of such well-known surgeons «s 
Sir James Paget, Simon, Savory, Callender, Barclay 
and others equally distinguished ; while among the 
American revisers we recognize men of nole=s celeb- 
rity. With regard to the mechanical execution of 
tht work, neither pains nor money seem to have 
been spared by the publishers —Med. and Surg. 
Reporter, Sept. 14, 1S81. 

In the revision of the work for the American edi- 
tion, not only has provision been made for a recog- 
nition of the advances made in onr knowledge dur- 
ing the ten years since its first publication, but also 
for a presentation of the variations in practice which 
characterize American surgery, and distinguish it 
from that of Great Britain. The work is one which 
we take pleasure in commending to the notice of our 
readers as an encyclopaedia of surgical knowledge 
and practice.— Sc. Louis Oouri r of Medicine, Nov. 
1881. 



D 



RUITT (ROBERT), M.R.G.S., Sfc. 

THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. 

A new and revised American, from the Eighth enlarged and improved London Edition . Illus- 
trated with four hundred and thirty -two wood engravings. In one very handsome octawo 
volume, of nearly 700 large and closely printed pages. Cloth, $4 00 ; leather, $5 00. 



28 



Henry C. Lea's Son & Co.'s Publications — (Surgery). 



f> R FA N T ( TITO MA 8) , F.R. C.S. , 

-»-' Surgeon to Quy * Hospital. 

THE PRACTICE OF SURGERY. Third American, from the Third 

and Revised English Edition. Thoroughly revised and much improved, by John B. 
Roberts, A.M., M.D. In one large and very handsome imperial octavo volume of 
1009 pages, with 735 illustrations. Cloth, $6 50; leather, $7 50 ; very handsome half 
Russia, raised bands, $8 00. (J ust Issued.) 



Blr. Blount's work lias long been a favorite one 
wilh surgeons. Ac its name indicate", it it of a tho- 
roughly practical character. It is distinctly indi- 
vidual in that it gives ihe results of the author's 
large and varied experience as an operator and cli- 
nical teacher, aid is on that account prized deserv- 
edly high M an original work. The style is neces- 
gari'lv condensed, the descriptions of surgical dis- 
rtef hi) (I to the point. The illustrations are 
well chosen, and the typical cases of the author's 
experience a re full of Interest, and are of more than 
oiuinary value to the working surgeon. — N: 1'. 
Medical Record, March 6, ism. 

It is a work especially adapted to the wants of 
students and practitioners. While not prolix, it 
aff>rds instruction in sufficient detail for a full un- 
derstanding of surgical principles and the treat- 
ment of Burgical diseases. It embraces in its scope 
all the diseases that are recognized as belonging to 
surgery, and all traumatic injuries. In discussing 
these it has seemed to be the aim of the author 
rather to pretent the student with practical infor- 
mation, a od that alone, than to burden his memory 
with the views of ditferent wrilers. however dis 
tinguished they might have been. In this edition 



the whole work has been careful lyre vised, ranch of 
it has been rewritten, and import a ut additions have 
been made to almost every chapter. — Cincinnati 
Med. New*, Jan. 1SSI. 

The Euglish edition, from which this is printed, 
has been carefully revised and rewritten; almost 
every chapter has received additions, and nearly 
one hundred new cuts introduced. The labors of 
the American editor, Dr. John B. Roberts, have 
very ranch increased the value of the book. He 
has introduced many new illustrations and much 
new material not found in the English edition. 
He has written, too, with great conciseness, which 
is a rare virtue in an American editor of an English 
work. If one could procure or wished only one 
sargery, ihis volume would certainly be selected. 
If he desired two, Erichfen's Surgery would be 
added, and if he wished a third, Gross' Surgery 
would justly be the work selected. As the great 
work of Gioss is amply sufficient for the wants of 
any surgeon, the priority given to Erichsen, and 
above all others, to this work of Bryant, is no 
labored eulogy of the last volume, but a simple and 
]u.-t statement of its demonstrable and pre-eminent 
merits.— Am. Med. Bi- Weekly, Feb. 26, 1881. 



TfRICRSEN {JOHN E.), F.R.S., F.R.C.S. 

J-^ Professor of Surgery in Universuy College, London, etc. 

THE SCIENCE AND ART OF SURGERY ; being a Treatise on Sur- 
gical Injuries, Diseases and Operations. Carefully revised by the Author from the 
Seventh and enlarged English Edition. In two large and beautiful octavo volumes of 
nearly 2000 pages, illustrated by eight hundred and sixty-two engravings on wood. 
Cloth, $8 50 ; leather, $10 50; half Russia, raised bands, $11 50. (Lately Issued.) 

The seventh edition is before the world asthe last 
word ot surgical science. There may be monographs 
which excel it upon certain points, but as a con- 
spectus upon surgical principles and practice it is 
unrivalled. It will well reward practitioners to 



Of the many treatises on Surgery which it has beeL 
our task to study, or our pleasure to read, there is none 
which in all points has satisfied us so well as the classic 
treatise of (Erichsen. His polished, clear style, his free- 
dom from prejudice and hobbies, his unsurpassed srra.'p 
of his sul ject, and vast clinical experience, quality him 
admirably to write a model text-book. When we wish, 
at the least cost of time, to learn the most of a topic ii 
surgery, we turn, by preference, to his work. It is » 
pleasure, therefore, to see that the appreciation of it is 
general, and has led to the appearance of another edi 
tion— MM. and Surg. Reporter, Feb. 2, 1878. 

Notwithstanding the increase in size, weobserve that 
much old matter has been omitted. The entire work 
has been thoroughly written up. and not merely amend 
ed by a few extra chapters A great improvement has 
been made in the illustrations. Oue hundred and fifty 
new ones have been added, and many of the old ones 
have been redrawn The author highly appreciates thi 
favor wilh which his work has been received by Ameri- 
can surgeons, and has endeavored to render his latest 
edition more than ever worthy of their approval. That 
be has succeeded admirably, must, we think, be the 
general opinion. We heartily recommend the book t< 
both student and practitioner.— N. Y. Med. Journal. 
Feb. 1878. 



read it, for it Las been a peculiar province of Mr. 
Erichsen to demonstrate the absolute interdepend- 
ence of medical and surgical science We need 
scarcely add, in conclusion, that we heartily com- 
mend the work to students that they may be 
grounded in a sound faith, and to practitioners as 
an invaluable guide at the bedside.— Am. Practi- 
tioner, April, 1878. 

For the past twenty years Erichsen's Surgery has 
maintained its place as the leading text-book, not only 
in this country, but in Great Britain. That it is able 
to hold its ground, is abundantly proven by the tho- 
roughness with which the present edition has been 
revised, and by the large amount of valuable mate- 
rial that has been added. Aside from this, one hun- 
dred and fifty uew illustraiions have been inserted, 
including quite a number of microscopical appear- 
inces of pathological processes. So marked is this 
change for the better, that the work almost appear* 
as an entirely new one. —Med. Record, Feb. 23,187r. 



R 



OLMES {TIMOTHY), M. A., 

Surgeon to St. George's Hospital, London. 

SURGERY, ITS PRINCIPLES AND PRACTICE. In one hand- 

some octavo volume of 968 pages, with 411 illustrations. Cloth, $6; leather, $7 ; half 
Russia, $7 50. 



It will be found a most excellent epitome of sur- 
gery by the general practitioner who has not the 
time togiveattentionto more minute and extended 
works, and tothemedicalstudent. Infact, weknow 
of no one we can more cordially recommend. The 
author has succeeded well in giving a plain and 
practical account of each surgical injury and dis- 
ease, and of the treatment which is most com- 
monly advisable. It will no doubt become a popu- 
lar workin the profession, and especially as a text- 
book.— Cincinnati Med. News, April, 1876. 

This is a work which has been looked for on both 
sides of the Atlantic with mnch interest. Mr. Holmes 



Is a surgeon of large and varied experience, and one 
)f the best known, and perhaps the most brilliant 
writer upon Burgical subjects in England. It is a 
oook for students— and an admirable one— and for 
the busy general practitioner. It will givea student 
ill the knowledge needed to pass a rigid examina- 
tion. The book fairly justifies the high expectations 
that were formed of it. Its style is clear and forcible, 
even brilliant at times, and the conciseness needed 
to bring it wit hi nits proper limits has not impaired 
Its force and distinctness. —N.T. Med. Record, April 
14, 1876. 



Henry C. Lea's Son & Co.'s Publications — {Ophthalmology). 29 



by ELLS ( /. SO ELBE KG), F.R.C.S. 

' f Professor of Ophthalmology in king's College Hospital, London, Ac. 

A TREATISE ON DISEASES OF THE EYE. Third American, 

from the Third London Edition. Thoroughly revised, with copious additions, by Charles 
S. Bull, M.D., Surgeon and Pathologist to the New York Eye and Ear Infirmary. In 
one large and very handsome octavo volume of 883 pages, with 254 illustrations on 
wood, six colored plates, and selections from the Test-types of Jaeger and Snellen. 
Cloth, $5; leather, $6 ; half Russia, raised bands, $6 50. 
This new edition of Dr. Wells's great work on the 
eye will be welcomed by the profession at large as 
weli as by the oculist It contains much new matter 
relating to treatment and pathology, and is brought 
thoroughly up with the present aatus of ophthal- 
mology. Its chapter ou refraction and accommo- 
dation — a subject much discussed of late years, and 
of great importance — is exceedingly complete. — 
Louisville Med. News, Nov. 13, 1SS0. 



The merits of Wells's treatise on diseases of the 
eye have been so universally acknowledged, and are 
so familiar to all who profess to have given any at- 
tention to ophthalmic surgery, that any discussion 
of them at this late day will be a work of superero- 
gation. Very little that is practically useful in re- 
ceat ophthalmic literature has escaped the editor, 
and the third American edition is well up to the 
times. As a text-book on ophthalmic surgery for the 



English-speaking practitioner, it is without a rival. 
— Am. Journ. of Med. S<i., Jan. 1881. 

The work has justly held a high place in English 
ophthalmic literature, and at the time of its first ap- 
pearance was the best treatise of its kind in the lan- 
guage. In the second edition, the author showed 
industrious research in adding new material fiom 
every quarter, and his spirit was eminently candid. 
A work thus built up by honest effort should not be 
suffered to die, and we are pleased to receive this 
third edition from the hands of Or. Bull. His labor 
his been arduous, as the very great number of addi- 
tions bracketed with his initial testify. Under 
the editorship which the third edition has enjoyed, 
the work is sure to sustain its good reputation, and 
to maintain its usefulness. — 2V. Y. Med. Journ., Jan. 
1881. 



KTETTLESHIP {EDWARD), F.R.G.S., 

-*-» Ophthalmic Surg, and Led. on Ophth. Surg, at St. Thomas' Hospital. London. 

THE STUDENT'S GUIDE TO DISEASES OF THE EYE. New 

Edition. With a Chapter on the Detection of Color-Blindness. By William Thomson, 
M D., Ophthalmologist to the Jefferson Medical College. In one royal 12nio. vol. of 

(Nearly Ready.) 



about 400 pages, with 138 illustrations 
This new edition of an excellent handbook embo- 
dies several improvements. A brief but clear intro- 
duction to the principles of geometrical optics so far 
as they concern the ophthalmist, will be hailed by 
many a student whose preliminary scientific lessons 
are fading from his mind. The advantage to all 



readers of having this risumi of physical principles 
thus readily at hand is manifest. We confidently 
recommended the first edition ; we have only now 
to congratulate the author on his assured success. — 
The Practitioner, Nov. 1882. 



a 



B 



'ARTER {R. BRUDENELL), F.R.G.S., 

Ophthalmic Surgeon to St. George's Hospital, etc. 

A PRACTICAL TREATISE ON DISEASES OF THE EYE. Edit- 
ed, with test-types and Additions, by John Green, M.D. (of St. Louis, Mo.). In one 
handsome octavo volume of about 500 pages, and 124 illustrations. 

ROWNE [EDGAR A.), 

Surgeon to the Liverpool Eye and Ear Infirmary, and to the Dispensary for Skin Diseases. 

HOW TO USE THE OPHTHALMOSCOPE. Being Elementary In- 

structions in Ophthalmoscopy, arranged for the Use of Students. In one small volume, 
royal 12mo., of 116 pages, with 35 illustrations. Cloth, $1. 



-pSMARCH {Dr. FRIED RICH), 

-U Professor of Surgery at the University of Kiel, etc. 

EARLY AID IN INJURIES AND ACCIDENTS. 

Lectures. Translated by H. R. H. Princess Christian. In < 
small 12mo. of 109 pages with 24 illustrations. Cloth, 75 cents. 



LAURENCE'S HAND ST -BOOK OF OPHTHALMIC 
SURGERY, for the use of Practitioners. Second 
Edition, revised and enlarged With numerous 
illustrations. In one very handsome octavo vol- 
ume. Cloth, $2 75. 

LAWSON ON INJURIES TO THE EYE, ORBIT 
AND EYELIDS: Their Immediate and Remote 
Effects. With about one hundred illustrations. 
In one very handsome octavo volume. Cloth, 
*3 50. 

GIBSON'SINSTITUTES AND PRACTICE OF SLR- 
aERT. Eighth Edit'n, improved and altered. With 
thirty-four plates. In two handsome octavo vol- 
umes, aboutlOOOpp. Leather, $6 50. 

MILLER'S PRINCIPLES OK SURGERY. Fourth Ame- 
rican, from the Third Edinburgh Edition. In one 
large 8vo. vol. of 700 pages, with 340 illustrations, 
Cloth, $3 75. 

MILLER'S PRACTICE OF SURGERY. Fourth Ame 
riean, from the last Edinburgh Edition. Revised hy 
theAaierican editor. In onefargeSvo. vol. of nearly 
700 pages, with 364 illustrations. Cloth, $3 76. 



Five Ambulance 

ne handsome volume, 
(Just Ready ) 



SARGENT ON BANDAGING AND OTHER OPERA- 
TIONS OF MINOR SURGERY. New Edition, with 
an additional chapter on Military Surgery. One 
12mo. vol. oi383Dag9BWithl8I wood-cuts. Cloth, 
$176. 

PflE PRINCIPLES AND PRACTICE OF SURGERY 
By William Pirrie.F.RS.E., Profes'roi Surgery 
in the University of Aberdeen. Edited by John 
NeilL, M.D., Professor of Surgery in the Penna. 
Medical College, Surg' n to the Pennsylvania Hos- 
pital, &c. In one very handsome octavo vol. of 
780 pages, with 316 illustrations. Cloth, $3 75. 

SKEY'S OPERATIVE SURGERY. In 1 vol. 8vo. 
of 661 pages, with 81 woodcuts. Cloth, $3 25. 

COOPER'S LECTURES ON THE PRINCIPLES AND 
Practice op Surgery. Inl vol. 8vo. 750 p. CPh$2. 

ASHTON ON THE DISEASES, INJURIES, AND 
MALFORMATIONS OF THE RECTLM AND 
ANUS : with remarks on Habitual Constipation. 
Second American, from the Fourth and Enlarged 
London Edition. With illustrations. In one 8vo. 
vol. of 287 pages. Cloth, $3 25. 



80 Henry C. Lea's Son & Co. '8 Publications — (O/oL, Med. Juris., etc). 

"BURNETT {CHARLES H.), A.M , M.D., 
•*-* Aural Surg to the T>re*b. Botp., Surgeon-in-ihargi- of the Jn fir. for Vis. of the Ear,Phila. 

THE EAR, ITS ANATOMY, PHYSIOLOGY AND DISEASES. 

A Practical Treatise for the Use of Medical Students and Practitioners. In one hand- 
some octavo volume of 619 pages, with eighty-seven illustrations: Cloth, $4 50; 
leather. $5 50; very handsome half Russia, raised bands, $6 00. 
On account of the great ad ranees which h:tve been 

made of late years in otology, and of the iucreased 

Interest manifested in it, the medics I profession will 



relcome this new work, which jh aseuta clearly and 
concisely it* j.re-eut aspect whilst clearly indi- 
ig the direction in which further researches cai 



the space at onr command forbid. Perhaps it is bet- 
ter, as the book ought to be in the hand* of every 
medical student, and its study will well repay the 
busy practitioner in the pleasure he will derive from 
the agreeable style in which many otherwise dry 
and mostly unknown subjects are treated. To the 



be most profitably carried on. Dr. Burnett from his ! specialist the work is of the highest value, and his 
own matured experience, and availing himself of | sense of gratitude to Dr. Burnett will we hope, be 
the observations and discoveries of others, has pro- | proportionate to the amount of benefit he can obtain 
duced a work which, as a text-hook, Stands /art/* | from the careful study of the book, and a constant 
prineepa in our language. We had marked several i reference to its trustworthy pages.— Edinburgh 
pa -sages as well worthy of quotation and the at ten- Med. Jour., Aug. 1878. 
tion of the general practitioner, but their number and 1 



POLITZER {ADAM), M.D., 
Imperial- Royal ProJ*esor ■/ Aural Therapeutics in the University of Vienna. Chief of the Impe- 
rial-R >uol University Clinic for Diseases of the Ear in the General Hospital, Imperial- 
Rnyal Public Aurist to thr city of Vienna. 

A TEXT-BOOK OF THE EAR AND ITS DISEASES. Translated 

at the Author's request, by James Patterson Cassblls, M.D., F.F.P.S. In one hand- 
some octavo volume of 800 pages, with 257 illustrations. Cloth, $5 50. (Just Ready.) 

rfA YLOR [ALFRED S.), M.D., 

J- Lecturer on Med. Jurixp. and Chemistry in Guy's Hospital. 

A MANUAL OF MEDICAL JURISPRUDENCE. Eighth Ameri- 

can from the Tenth London Edition, thoroughly revised and rewritten. Edited by John 
J. Reese, M.D., Professor of Medijal Jurisprudence and Toxicology in the University 
of Pennsylvania. In one large octavo volume of 937 pages, with 70 illustrations. 
Cloth, $5; leather, $6; half Russia, raised bands, $6 50. (Lately Issued.) 
The American editions of this standard manual ever, we should only have to seek for laudatory 
have for a long time laid claim to the attention of terms.— Am. Jour n. of Med. Sci., Jan. 1S81. 
the profession in this country; and that the profes- It win 8ufflce t0 re mark that this new edition 
won has recognized tms claim with favor is proven show8 the 8i as of j ud i cioag revision A great unm- 
by the ca for frequent new editions of the work. ber of illustrative medico-legal cases winch have 
This one, the eignth, comes betore us as embodying 0CC[irred 8iace the last edition was pursued are 
the latest thoughts and emendations o. Dr. Taylor, cited in [heir connection, and add much to 

upon the subject to which he devo ed his lite with the iateregt and value of the work. There is ample 
an assiduity and success which made him facile. evideiice that this admirable book will maintain its 
pHnrepa among English writers on medical juris- hi h Uce as a 8taQdard authorih concerning the 
prudence. Both the author and the book have m l ti £ a of whicn it , reat8 . -Boston Medical and 
made a mark too deep to he affected by criticism, 8urgtml r ournal Jan . 13 1S81 . 
whether it he censure or praise. In this case, how- 

jr>T THE SAME AUTHOR. 

THE PRINCIPLES AND PRACTICE OF MEDICAL JURIS- 
PRUDENCE. Third Edition. In two handsome octavo volumes. (In Press.) 
T>T THE SAME AUTHOR. 

POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND 

MEDICINE. Third American, from the Third and Revised English Edition. In one 
large octavo volume of 788 pages. Cloth, $5 50 ; leather, $6 50. 
The present is based upon the two previous edi- all that is required to be known about the present 
tions; but thecomplete revision rendered necessary book is that the author has kept it abreast with the 
by time has converted it into a new wirk." This times. What makes it now, as always, especially 
statement from the preface contains all th*t it is de- valuable to the practitioner is its conciseness and 
sired to know in reference to the new edition. The practicalcharacter,only those poisononssubstances 
works of this author are already in the library of being described which give rise to legalinvestiga- 
every physician who is liable to be called upon for tions. — The Clinic, Nov. 6, 1876. 
medico-legal testimony (and what .>ne is not?), so that 



rpIDY{CHARLES MEYMOTT), MB., F.C.S , 

J- Professor of Chemistry and of Forens,c Medicine and Public Health at the London Hospital, etc. 

LEGAL MEDICINE. Volume I. Embracing Evidence, The Signs 

ok Death, Identitv, The Causes of Death, The Post-Mortem, Sex, Monstrosities, 
Hkrmaphrodism, Expectation ok Life, Prbsumption ok Death and Survivorship, 
Heat and Cold, Burns, Lightning, Explosives, Starvation. Making a very hand- 
some imperial octavo volume of ti(34 pages, with 2 beautifully colored plates. Cloth, $6; 
leather, $7. (Just Ready.) 
We can highly recommend Dr. Tidy's book to the I crease the author's reputation as a medical jurist. 

profession as a solid contribution to the suoject of —British Medical Journal, Oct. 28, ItiSi. 

Forensic Medicine, and one which cannot fail to in- | 



Henry C. Lea's Son & Co.'s Publications — (Miscellaneous). 31 



'DO BERTS { WILLIAM), M.D., 

■*■ «* Lecturer on Medicine in the Manchester School of Medicine, etc. 

A PRACTICAL TREATISE ON URINARY AND RENAL DI£- 

EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. 
Fourth American, from the Fourth Revised and Enlarged London Edition. In one 
large and handsome octavo volume- (Preparing.) 

[THOMPSON {SIR HENRY), 

•*■ Surgeon and Professor of Clinical Surgery to University College Hospital . 

LECTURES ON DISEASES OF THE URINARY ORGANS. With 

illustrations on wood. Second American from the Third English Edition. In one 
octavo volume of 203 pages, with 25 illustrations. Cloth, $2 25. 
T>T THE SAME AUTHOR. 

ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 

THE URETHRA AND URINARY FISTULA. With plates and wood-cuts. From the 
Thirdand revised English Edition. In one very handsome octavo volume. Cloth, $3 50. 



BASHAMON RENAL DISEASES: A Clinical Guide 

to f heir Diagnosis and Treatment. In one 12mo. 

vol. of 304 pages, with illustrations. Clofb,$2 00. 
A TREATISE ON FEVER. By Robert D. Lyons. 

K.C.C. In one octavo volume of 362 pages, 

Cloth, *2 26. 



LECTURES ON THE STUDY OF FEVER. By A. 

Hudson, M.D., M.R.I. A., Physician to the Meath 

Hospital. In one vol. 8vo. Cloth, $2 50. 

STOKES' LECTURES ON FEVER. Edited by John 

William Moore, M.D., F. K.Q C. P. In one octavo 

I volume of 26-1 pages. Cloth, $2 00. 



rfUKE {DANIEL HACK), M.D., 

J- Joint author of The Manual of Psychological Medicine, &c. 

ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON 

THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the 
Imagination. New Edition In one handsome octavo volume (Preparing .) 

RLANDFORD {G. FIELDING), M.D., F.R.C.P., 

■*-* Lecturer on Psychological Medicine at the School of St. George's Hospital, Ac. 

INSANITY AND ITS TREATMENT: Lectures on the Treatment, 

Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the 
United States on the Confinement of the Insane. By Isaac Rat, M.D. In one very 
handsome octavo volume of 471 pages. 



EA {HENRY C). 

SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF 

LAW, THE WAGER OF BATTLE, THE ORDEAL AND TORTURE. Third Revised 
and Enlarged Edition. In one handsome royal 12mo. volume of 552 pages. Cloth, 
$2 50. (Lately Issued.) 

more accurate than either of the preceding, but, 
from the thorough elaboration is more like a har- 
monious concert and less like a batch of studies. — 
The Nation, Aug. L, 1S7S. 

Many will be tempted to say that this, like the 
"DeclineandFall,"isone of the uucriticizable books. 
Its facts are innumerable, its deductions simple and 



This valuable work is in reality a history of civi- 
lization as interpreted by the progress of jurispru- 
dence. . . . In "Superstition and Force" we have 
a philosophic survey of the long period intervening 
between primitive barbarity and civilized enlight- 
enment. There is not a chapter in the work that 
should not be most carefully studied, and however 
well versed the reader may be in the science of 
jurisprudence, he will find much in Mr. Lea's vol- 
ume of which he was previously ignorant. The 
book is a valuable addition to the literature of 
social science. — Westminster Review, Jan. 1880. 

The appearance of a new edition of Mr. Henry C. 
Lea's "Superstition and Force" is a sign that our 
highestscholarship is not without honor in its na- 
tive country. Mr. Lea has met every fresh demand 

for his work with a careful revision of it, and the I Magazine, Oct. 187S. 
present edition is not only fuller and, if possible, | 

J£Y THE SAME AUTHOR. 

STUDIES IN CHURCH HISTORY. THE RISE OF THE TEM- 

PORAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. New Edition. 
In one very handsome royal octavo volume of about 500 pages, (hi Press.) 
A few notices of the previous edition are appended. 
Tue story was never told more calmly or with 
greater learning or wiser thought. We doubt, indeed, 
if any other study of this field can be compared with 
this for clearness, accuracy, and power. — Chicago 
Examiner, Dec. 1870. 



inevitable, and its chevaux-dt-frise of references 
bristling and dense enough to make the keenest, 
stoutest, and best equipped assailant think twice 
before advancing. Nor is there anything contro- 
versial in it to piovuke assault. The author is no 
polemic. Though he obviously feels and thinks 
strongly, he succeeds in attaining impartiality. 
Whetier looked on as a picture or a mirror, a work 
such as this has a lasting value. — Lippineott's 



Mr. Lea's latest work," Studiesin Church History," 
fully sustains the promise of the first. It deals with 
three subjects — the Temporal Power, Benefit of 
Clergy and Excommunication, the record of which 



las a peculiar importancefor the English student.and 
is a chapter on Ancient Law likely to be regarded as 
final. We can hardly pass from our mention of such 
works as these — with which that on "Sacerdotal 
Celibacy" should be included — without noting tbe 
literary phenomenon that the head of one of the first 
American houses is also the writer of some of its most 
original books.— London Athenaeum, Jan. 7, 1871. 



8 2 



Henry C. Lea's Son & Co.'s Publications. 



INDEX TO CATALOGUE. 



American Journal of the Medical Sciences 

American system of Gynacology 

Alien'b Anatomy . 

•A. -hi. ■,- 

A-hiou on the Kectum and Anui 

Ash we 11 on Diseases ol W< men 

Attneid's Chemistry . 

Barlow's Practice ofMedicine 

Barnes' Midwifery 

•Biraeauu Dieeattl of Women 

Bartholow on Electricity 

Basham on Rem 

Bellamy's Surgical Anatomy 

Blaudford on Insanity . 

Bloxaru's Chemistry 

Bowman's Practical Chemistry 

•Brist,.we's Practice 

Browne on Ophthalmoscope . 

Browne on the Throat . 

*rf: v. t ut .- Practice of Surgery 

*Bum»tead on Venerea] 

•Burnett on the Ear 

•Carpenter's Human Physiology 

C irpeuter on the Use and Abuse of Alcohol 

Carter on the Eye .... 

Century of American Medicine . 

Chad wick on Diseases of Women 

Chambers on Diet and Regimen 

Churchill on Puerperal Fever 

Classen's Chemistry 

Cieland's Dissector 

Clowes' Chemistry 

Coleman'? Dental Surgery . 

Condie on Diseases of Children . 

Cooper's Lectures on Surgery 

•Cornil and Ranvter's Pathological Histology 

Cornil on Syphilis .... 

Cullerier's Atlas of Venereal Disease 

•Dalton's Human Physiology 

Davie' Clinical Lectures 

Druitt's Modern Surgery . 

Duncan on Diseases of Women . 

•Duugli.-on'r Medical Dictionary 

Edis on Diseases of Women . 

Ellis' Demonstrations in Anatomy 

•Emmet's Gyusecology 

•Krlchsen's System of Surgery 

E^march's Early Aid in Injuries and Accidents 

P&rquhaTSOn'a Therapeutics 

Fenwick's Diagnosis . 

Finlayson's Clinical Diagnosis 

Flint on Auscultation and Percos 

Flint on tue Heart 

Flint on Phthisis . 

Flint on Respiratory Organs 

•Flint's Clinical Medicine . 

Flint's Essays 

♦Flint's Practice of Medicine 

Foster's Physiology . . 

•Fothergill's Handbook of Treatment 

Fjwnes' Elementary Chemistry 

Fox on Diseases of the Skin 

Fuller on the Lungs, &c. . 

Galloway's Analysis .... 

Gibson s Surgery 

Gluge's Pathological Histology, by Leidy 

•Gray's Anatomy 

Greene's Medical Chemistry 
Green's Pathology and Morbid Anatomy 
Griffith's Universal Formulary . 
Gross on Foreign Bodies in Air-Passages 
Gross on Impotence and Sterility 
Gross on Urinary Organs . 
* Jross' Sy-tem of Surgery 
Gu6serow on Dlerine Tumors 
Gynecological Transactions . 
Habershcn on the Abdomen . 
•Hamilton on fractures and Dislocations 
Hamilton on Nervous Diseases . 



Hartshorne's Anatomy and Physiology 

Hartsnorne's Conspectus of the Medical Sciences 

H art.- home's Essentials of Medicine . 

Hugh's Practical Anatomy . 

Hermann's Experimental Pharmacology 

Hillier's Handbook of Skin Disease* 

Hill on Venereal Diseases . 

H oblyn's Medical Pietionary . 

Hodge's Obstetrics .... 

Books marked * are also bound in half Russia 



3 (lodge on Women 
28 Hoifmann and Power's Chemical Analyst 

7 Holden's Landmarks . 

•Mind's Medical Sute6and Keflectiont 
28 * Holmes' Surgery 
13 •Holmes' System of Surgery 

8 Horner's Anatomy and Histology 
11 Hndson on Fever . 
24 Hyde on the Diseases of the Skin 
22 Jones (C. Handheld) on Nervous Disorders 
18 Keating on Infant 



Kn 



rgery 



2 • 



1 ol Obstetrics 
."cheou Pneumonia, Mtlaria, &< 
31 i La Roche on Yellow Fevei . 
10 I Laurence and Moon's ophthalmic St 
9 Lawson on the Eye 
1-i Lea s Studies in Church History 
29 | Lea'sSuperstitionand Force 

19 j Lee on Syphilis .... 
28 | Lehmann's Chemical Physiology 

•Leishman'e aiidwifery 

Ludlow's Manual of Examinations 

Lyons on Fever .... 

Maisch's Materia Medica 

Medical News .... 

Meigs on Puerperal Fever . 
23 Miller's Practice of Surgery 
It Miller's Principles ot -urgery 
23 Mitchell's Nervous Diseases of Womi 
9 I Montgomery on Pregnancy 

6 Morris on Skin Diseases 

10 Neill and Smith's Compendium of Med Science 

26 Nettleship on Di.-eascs of the Eye 
2.1 *Parrishs Practical Pharmacy . 
28 Pa li y on Extra-Uterine Pregnancy 
'3 Parvin's Midwifery 

20 Pavy on Digestion 
20 I Pirrie's Svstem of Surgery . 

8 [ *Playfair''s Midwifery . 

15 Playfair on Nerve Prostration and Hysteria 

27 Politzer on the Ear . 
23 t Rainsbotham on Parturition 

4 Rem sen's Principles of Chemistry 

22 *Reynolds' System of Medicine . 

7 Richardson's Preventive Medicine 

23 Roberts' Principles and Practice of Surgery 

28 , Robertson Urinary Diseases 

29 Rodwell's Dictionary oi Science . 

11 | Sargent's Minor Surgery 

14 Schafer's Histology 

16 Seller on the Throat 
19 Sharpey and Quain's Anatomy 
19 I Skey's Operative Surgery . 
19 Slade on Diphtheria . 
1ft Smith (Edward) on Consumption 

15 , Smith (Eusi.) on Wasting Diseases in <M>ildrei 
]5 \ Smith (H. H.) and Homers Anatomical Ada* 



10 I *Smith iJ.L.)on Child 

8 •Stllle & Maisch's Dispensatory 
14 *>'lille's Therapeutics . 

10 Stimson on Fractures . 

19 I Samson's Operative Surgery 
1H | Stokes on Fever 

9 I Siarges' Clinical Medicine . 
29 i Tanner on Pregnancy . 
14 ] Tanner's Manual oi Clinical Medicine 

6 *Taylor's Medical Jurisprudence 

9 ! Taylor's Priu. and Prac. of Med. Juri 

13 I Taylor on Poisons 

11 I *rhomason Diseases of Wouen 
2b ; Thompson on Stricture . 

20 I Thompson on Urinary Organs 
26 '. Tidy's Legal Medicine 
2d Todd on Acute Diseases 
23 | Tuke on the Influence of the Mind 
22 Walsheon the Heart . 

14 Watson's Practice of Physic 
L'o *SVell8 on the Eye 
18 Weston Diseases of Children . 

West on Diseases of Women 

West on Nervous Disorders ofChildren 

Williams on Consumption . 

Wilson'* Handbook of Cutaneous Medicin 

Wilson's Human Anatomy . 

Winckel on Childbed . 

Wiihler's Organic Chemistry 

Woodbury's Practice . 



prudence 



HENRY C. LEA'S SON & CO.— Philadelphia. 



I *s 



&i 



*« 



1 



